AO Dialogue 2|12 The newsletter for the AO community
Surgical Implant Generation Network (SIGN)
Reports from the annual SIGN conference in Richland, Washington, US Impressions from AO SEC Chairman John Croser AO SEC faculty in developing countries have often encountered the SIGN nail in use for intra-medullary fixation. At our meeting in Davos in June 2012 the AO SEC committee had discussed whether the SIGN implant should be used in courses. It was therefore opportune when Jim Kellam, Dialogue Editor-in Chief, suggested that Susanne Bauerle, AOTrauma ORP, and I should attend the 2012 annual SIGN conference. The four day course was themed “Treatment of difficult fracures” and included clinical presentations, workshops on plastic bones and a full social program. The striking
feature of the conference was the close association between the founder, Lewis (Lew) Zirkle, the SIGN administrative and production staff, and the surgeons from developing countries who are using the SIGN nail. The clinical sessions were quite astounding in terms of the complexity of the fractures and the recorded outcomes—all highlighted by “squat and smile” photos—the unique outcome measure developed by SIGN.
Table of contents SIGN reports My view, James Kellam
4
DKOU conference update
5
Clinical Divisions
6-9
Berton Rahn prize
10
AO Institutes The package of SIGN instruments and a starter set of nails of various sizes are provided free [ continued on page 2 ]
1-4
AO President’s interview
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Surgical Implant Generation of charge to selected clinics and resupply of nails is dependent on the reporting of results to the central database. The pivotal feature of the SIGN system is that cross-locking can be achieved without the need for x-ray guidance which significantly reduces the need for expensive infrastructure. You could not help but be impressed by the results being achieved with complex fractures in developing countries many racked by war and civil strife. In these countries the fractures are often the result of gunshot wounds, shrapnel wounds or blast injuries and a significant proportion are open fractures. Many of the cases presented involved failed conservative treatment or failed previous fixation and so were at the upper end of the spectrum of difficult fractures. I found many similarities between AO and SIGN in terms of the philosophy and ethics of the two organizations and I believe it would be to our mutual benefit to work together in developing countries. To learn more about the work of SIGN log on to www.signfracturecare.org
AO Dialogue-SIGN Fellow Duong Bunn reports on his experiences as an orthopedic trauma surgeon in Phnom Penh, Cambodia. On returning from my two-year residency at Victor Segalen Bordeaux University, France in 2000, I was appointed as Chief of Orthopedics at Preah Kossamak Hospital, Phnom Penh, Cambodia. My ambition was to develop my ward, my hospital and my country in this field. My first day of work set me back as I did not have a working C-arm, a traction table and useful implants. My requests for new affordable implants were denied forcing me to use local products and modify what we had. I fashioned an external fixator from a metal tube from India as well as making other necessary modib fications to treat both acute fractures and the large numbers of malunions and non-unions seen after traditional bone setting treatment. In January 2003, the director of HOPE hospital b NGO hospital in Phnom Penh, Cambodia) (an called me to transfer his SIGN Nail set to me. This was a wonderful breakthrough as it finally gave me something to treat my patients with.
All rights reserved. Any re production, whole or in part, without the publisher’s written consent is prohibited. Great care has been taken to maintain the accuracy of the information contained in this publication. However, the publisher, and/or the distributor and/or the editors, and/or the authors cannot be held responsible for errors or any consequences arising from the use of the information contained in this publication. Some of the products, names, instruments, treatments, logos, designs, etc. referred to in this publication are also protected by patents and trademarks or by other intellectual property protection laws (eg, “AO”, “TRIANGLE/GLOBE Logo” are registered trademarks) even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name, instrument, etc. without designation as proprietary is not to be construed as a representation by the publisher that is in the public domain.
Impressum AO Dialogue 2|12 Editor-in-Chief: James F Kellam Managing Editor: Olga Harrington Publisher: AO Foundation Design and typesetting: Manuel Kurth and AO Foundation, Communication & Events Printed by: BUDAG AG, Switzerland Editorial contact address: AO Foundation, Clavadelerstrasse 8, CH-7270 Davos Platz, Phone: +41 81 414 28 14, Fax: +41 81 414 22 97, E-mail: dialogue@aofoundation.org Copyright © 2012, AO Foundation, Switzerland Susanne Baeuerle and John Croser present the AO Dialogue SIGN Fellow Duong Bunn with his certificate
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Network (SIGN) continued…
2012 SIGN conference participants, speakers and staff gather for a group photo
Through my contact with Dr Lew Zirkle and Dr Tuan Hai (Ho Chi Minh, Vietnam) over the phone and email, I learned how to use the SIGN nail. After seeing my successful results, I communicated my SIGN nail experience to other Cambodian surgeons culminating on September 2, 2004, with my first regional SIGN Meeting with Dr Zirkle and Jeanne Dillner, CEO of SIGN. From this time, fracture patients realized that fracture care had improved in Cambodia. Now we are able to treat both acute injuries, as well as the non and malunions. In 2007, I arranged a regional and international SIGN Meeting which was attended by many doctors from Cambodia, Laos, Papua New Guinea, and Australia with a view to start-
ing SIGN programs in their countries or taking them to developing countries. In 2008, I was elected President of the Cambodia Society of Orthopedics and Traumatology and began a program to improve Cambodian orthopedic and traumatology care. Dr Dalton Boot from World Orthopaedic Concern (UK) and Dr Tim Keenan from Orthopedic Outreach (Australia) helped to build an extension at our hospital as well supplying equipment and implants. In June 2012, I went with Dr Thomas Vasileff (Alaska, US) to share my experiences on SIGN nail practice at a new program he sponsored. I was chosen in 2008 for the OTA SIGN Scholarship, and in 2012 as the AO Dialogue-SIGN fellow. It is my great honor to be awarded these prizes and to be a surgeon that helps many people. “Squat and smile”
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Surgical Implant Generation Network ‌end
My view James F Kellam Editor-in-Chief james.kellam@aofoundation.org
Is it time the AO started to collaborate with SIGN? The lead article of this AO Dialogue highlights the SIGN Annual Conference. For the past four years, AO Dialogue has sponsored a member of the SIGN Network to attend this meeting. Why has this been done? The AO Foundation for years has tried to understand its relationship with the developing world and fracture care management. This involvement has ranged from providing old implants, to a variety of education initiatives. Recently under the direction of Paul Demmer, Cleber Paccola and John Croser, AO SEC which is responsible for promoting AO in developing nations, has emphasized education as the way forward. They Conference workshop on plastic bones using the SIGN nail
Impressions from Susanne Baeuerle, Senior ORP Manager, AOTrauma The level of enthusiasm that the SIGN team (Lewis Zirkle, Joanne Dillner, the engineers and employees) showed for their common goal, supporting surgeons working with the SIGN nail in developing countries, was so inspiring. It was thrilling to meet surgeons that I have heard of in my work at the conference and learn about their knowledge of, or relationship with the AO Foundation.
have developed programs of reverse fellowships in Brazil, support of resident education in Africa, the development of non-operative fracture courses, operating room personnel courses and the production of literature through the AO Education Institute and AOTrauma. However, is this enough? SIGN (under Lew Zirkle’s leadership) has introduced an intramedullary nail which has become extremely popular in developing nations to provide low resource areas with an effective treatment for femoral and tibia diaphyseal fractures. SIGN is similar to the AO as it is based on
The level of detail in the presentations at the conference gave invaluable insights into what surgeons are doing with the SIGN nail which is extremely relevant and useful for people facing similar but different issues in the field. The AO Dialogue Fellow, Duong Bunn gave a wonderful presentation about his use of external fixation in neglected elbow luxations. Our attendance at the SIGN conference provided John Croser with a unique opportunity to present Bunn with his fellowship certificate and for me to give him what every surgeon needs, some chocolate knives from Switzerland.
the four pillars of research, education, development and documentation. The group has a large database of cases for research, runs educational courses and has a growing implant development program aimed at providing techniques and implants suitable for use in developing healthcare systems. It may now be time for the AO Foundation to consider collaborating with SIGN. This would allow us to build our expertise and surgical network for the improvement of fracture management in developing nations with the many groups and individuals who are interested in doing this. With our strong AO international presence, it may also be possible for the AO Foundation to use this strength to coordinate other organizations and funding foundations to improve fracture care through education and development.
AO Dialogue 2|12
DKOU—The biggest orthopedic event in Europe
Demonstrating the playground to interested surgeons at DKOU
The motto for the Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU) held in Berlin this year in October was “Quality, ethics and efficiency”. The interactive congress featured seminars and talks from various experts from throughout German-speaking Europe. With 242 exhibitors spread across nearly 6,000 square metres, more than 8,500 registered participant surgeons and scientists, 42 seminars, symposiums and workshops, the DKOU is the biggest congress in the world after the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) and the biggest in Europe for orthopedic surgery. The main topic this year concerned sports-related injuries especially in older people but other issues were addressed in several scientific lessons. The AO Foundation had a meeting lounge where AO members or interested doctors could have relax and meet colleagues. Booths from AOTrauma and AOSpine were integrated into the lounge. The AO playground demonstrated the AO methods to several visitors and was one of the key attractions of the AO lounge. AOTrauma organized a symposium on “How much micro movement is beneficial for fracture healing” where the Dynamic Locking Screw (DLS) technology was presented using various
Nikolaus Renner addresses the audience after the AOTrauma symposium
examples and studies. The symposium was moderated by Norbert Haas, Nikolaus Renner and Hans-Joerg Oestern. The interest was so high that the auditorium was not big enough to contain the audience. Afterwards the audience was invited to a reception at the AO lounge. In his address AOTrauma chairman Nikolaus Renner said that there are three main reasons for the AO presence at the congress: membership, encouraging surgeons to become a member of a worldwide network of knowledge; Global Needs Analysis, finding out what the doctors need for their daily work; and finally showcasing new AO Books like the latest from Babst/ Bavonratanavech/Pesantez “Minimally Invasive Plate Osteosynthesis” and “Principles of Internal Fixation of the Craniomaxillofacial Skeleton” from Ehrenfeld/Manson/Prein. Alongside AOTrauma and AOSpine, the AO Research Institute Davos (ARI) was also active with workshops and presentations. ARI director Geoff Richards gave lectures about “Bone compensatory material” and “Medulla stem cells” All in all the DKOU is one of the most important events for the AO and the visibility is crucial especially in the German language region.
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From the Clinical Divisions AOTrauma Realizing positive change In a previous issue of AO Dialogue, AOTrauma reported on how it is consolidating activities through governance changes, and more streamlined processes. Nikolaus Renner, AOTrauma International Board Chairperson, is now 18 months into his leadership position. Setting goals and moving forward as an organization, has been supported by our committed and sharply focused leadership. With the assistance of dedicated board members and regional representatives, AOTrauma is realizing positive change and planning for the future.
Global Needs Analysis Survey Engaging surgeons in an open dialogue about the development of future educational offerings is necessary for AOTrauma to continue supplying the highest quality education, while remaining relevant to surgeons. AOTrauma continues to gather quantitative and qualitative data through the Global Needs Analysis, an online survey project that seeks to learn about the clinical problems members face and their learning preferences. This project will provide key information to help ensure our educational activities meet the needs of practicing surgeons worldwide.
by our traditional course format. The strategic shift in delivery also includes powerful leveraging of the latest technologies. The transformation of AOTrauma Education will result is a comprehensive, diverse educational portfolio of educational activities and resources. It will support, at its core, the continued face-to-face interaction learning activities with the leading experts in the field.
Clinical Priority Program (CPP)—Bone infection The current Clinical Priority Program (CPP) addresses clinical challenges related to bone infections. The five-year research program aspires to improve physician experiences and patient outcomes with targeted, state-of-the-art projects funded by an investment of CHF 2.75 million. The selected consortium will be led by Stephen Kates from University of Rochester, New York and will include other international research partners as well as AOCID and ARI internally.
AOTrauma Community
Started in 2012, this transformation represents both a strategic and philosophical shift in our three pillars of education: faculty development, content development, and delivery of education activities. New formats have been, or are in the process of being developed to meet diverse set needs that are beyond provided
Providing valuable benefits and networking opportunities to members is an overarching aim that directs the efforts of AOTrauma. With members distributed all over the world, one of our strengths is the truly international nature of our organization. We are excitedly exploring how to meet the evolving needs of surgeons through each stage of their career. Benefits, including access to selected OVID journals, the network directory, free e-books, AOTrauma webinars and webcasts, bring tangible value to members. Exceeding 6,300 AOTrauma members globally; the reach is there, and the means are coming together.
AOTrauma Masters Workshop, Foot and Ankle with Anatomical Specimens
AOTrauma Course, Principles in Operative Fracture Management
AOTrauma Education Transformation
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AOSpine The journey ahead AOSpine International Chairperson Jeff Wang reflects on his first four months ‘in office’ and talks about the journey ahead to ensure that AOSpine is recognized as the premier global academic spine society. This year, innovation, research expansion, education, and new membership offerings by way of enhanced methods of delivering education at courses, symposia, and seminars; and developing new online media and collaboration platforms remain a priority.
Upcoming innovations With improvement and progress in mind, AOSpine will introduce its new web and tablet based Surgery Reference to the spine community as soon as end-2013, or early-2014. Supporting the increasing demand of its members, AOSpine is in the process of transforming InSpine Magazine from a print journal to a digital product. The new digital InSpine Magazine will be launched in March 2013, and cater to mobile, plugged-in spine care professionals. Later, the digital InSpine will include interactive content, online discussions, and links to AOSpine membership content to further enhance articles related to clinical and practice management.
Research AOSpine’s new and ongoing research initiatives continue to gather real evidence to appropriately judge clinical interventions, and improve patient care. The Spine Research Network—AOSpine’s translational research initiative—continues to explore the mechanisms behind degeneration and regeneration of the intervertebral disc. The Knowledge Forums, which are clinical research working
AOSpine Chairperson Jeff Wang and Past Chairperson Luiz Vialle
groups in the areas of Tumor, Deformity, and Spinal Cord Injury & Trauma, will commence to analyze their first results. In addition, a new Knowledge Forum on degeneration is in the process being formed.
A dynamic global community The AOSpine community is on a global growth curve! It is busy connecting members by way of organizing educational activities at regional and national levels, and creating initiatives that encourage member involvement, continually adding value to each other, and to the community. In 2012, local and global collaborations, along with cooperative educational efforts with regional spine societies, such as: the North American Spine Society (NASS), the Chinese Orthopaedic Association (COA), and the Spine Society of Europe (EuroSpine), have greatly contributed to the mission of AOSpine to become a truly global academic community.
Setting standards Following in the footsteps of AOSpine’s founders, Jeff Wang continues to realize the organization’s vision to be recognized as the premier global academic spine society by setting the standard for education and research. He strongly believes that the organization is on its way to building the most active and respected academic society that interacts on a worldwide basis, thanks to an extraordinary, dedicated, and knowledgeable community of spine care professionals, and AOSpine’s staff worldwide.The future is exciting, and AOSpine looks forward to celebrating the 10th anniversary in 2013!
AOSpine Davos Courses 2011 participants gaining hands-on experience
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From the Clinical Divisions AOCMF A growing community
Co-authored by Joachim Prein, Michael Ehrenfeld and Paul N. Manson, it presents the collective expertise and competence of different specialties, resulting in an all-inclusive work of considerable scope. AOCMF offers its members a 25% discount on the original price of both print and electronic versions.
AOCMF, a global leader in high quality post-graduate education in the craniomaxillofacial field, serves as the voice and professional resource for craniomaxillofacial trauma and reconstruction. As a member, your benefits include: access to the journal of Craniomaxillofacial Trauma & Reconstruction, online access to eight current and archives of 23 scientific journals, access to evidencebased rankings of publications (CMFline), AOCMF teaching videos, other online resources, discount on AO publications, and global membership support, to name a few.
The official AOCMF membership journal of Craniomaxillofacial Trauma and Reconstruction is in its fifth year of publication. AOCMF is reorganizing its structure and doubling its scientific content.
Technology-savvy education and publications
Increased education offerings
The online AO Surgery Reference describes the complete surgical management process from diagnosis to aftercare, and assembles relevant published AO material. The CMF section of AO Surgery Reference currently covers four anatomical areas: skull base and cranial vault, midface, dentoalveolar trauma, and mandible. There is also excellent material on congenital deformities, orthognathic, and postablative reconstruction.
AOCMF educational activities worldwide exceeded the 100 mark in 2012, with over 4,500 participants. The growth has mainly been seen in Asia Pacific and Latin America. North America, Europe, and the Middle East continue to remain stable.
AOCMF’s clinical evidence database application, the CMFline for the iPhone and Android-based mobile devices, provides bibliographic information on therapy, prognosis and diagnosis; and enlists key study results. The most recent CMF publication, Principles of Internal Fixation of the Craniomaxillofacial Skeleton— Trauma and Orthognathic Surgery, serves as a tribute to the individuals who have taught as AO faculty at courses and symposia over the last 50 years.
AOCMF International Retreat in Magaliesburg, South Africa, November 2012
The AOCMF Neurotrauma working group (founded in 2010 as subgroup to AOCMF Europe) is developing a new curriculum for Neurotrauma with an initial focus on the Principles Course in collaboration with AOCMF Education and AO Education. This year’s AOCMF International Retreat was attended by 70 members and guests. The program focused on the future development of AOCMF’s educational offerings, and included information from the AO Foundation, AOCMF Education, Community Development and Research & Development, and a session on educational program development. It presented the perfect opportunity for the international faculty to foster the community spirit.
CMFline
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AOVET A diverse and dynamic community The AOVET community is committed to improving the quality of patient care through state-of-the-art education, and provides a vital link for veterinary specialists across the globe. With a growing membership community of more than 600 individuals, AOVET is the leading organization in the field of veterinary medicine. Combining presentations from leading specialists with cutting-edge surgical skills and techniques on anatomic models is a well-established and proven method, allowing veterinary surgeons to effectively apply theory to practice and improve treatment techniques.
Vannini (Switzerland) and Daniel Damur (Switzerland). And, the Minimal invasive osteosynthesis, chaired by Loic Dejardin (USA) along with co-chair James Tomlinson (USA). Inviting attendees to the Davos Courses 2012, Jörg Auer, Chairperson, AOVET International, says “It is my profound belief that you will not regret having participated in any one of these two exceptional educational offerings. Come, join us and be a part of our ‘cool-n-competitive’ AOVET group.”
New book release Education Besides the well-established courses, AOVET organized a successful first-time small animal principles course in Cape Town, South Africa. Recently, Latin America has been established as a region chaired by Cassio Ferrigno from the University of Sao Paulo. The first Latin American Faculty Training was held in Brazil in November 2011. In response to the high demand of the Brazilian veterinarians, AOVET organized four instead of the three planned courses in Sao Paulo: one in equine principles, two small animal principles courses, and one small animal advanced course. Istanbul held the second international retreat this summer, focusing on the future of AOVET Education. The newly established European Board was invited to this event along with the AOVET international board and management of AO Foundation. At the Davos Courses 2012, AOVET has offered two courses: Advances in Small Animal Fracture Management, chaired by Rico
First AOVET Small Animal Principles Course in South Africa, October 2012
What and where was AOVET founded? Who was the first President of AOVET? Who was the first American AOVET President? What did the “Waldenburg Circle” represent? Who was “Maxlie”? For all interested in the history of AOVET, a new publication—History of AOVET—The First 40 Years will be released in time for the Trustee Meeting 2013 in Lima, Peru. History of AOVET—The First 40 Years is a combined effort by Auer J.A., Schlünder M., von Salis B., Kàsa, F., Kàsa G., Olmstead M., Fackelman, G.E., Pohler O; based on the work of Martina Schlünder, an understudy of Thomas Schilch, who published the history of the AO Foundation in: A Revolution in Fracture Care, 1950-1990s. Basingstoke: Palgrave Macmillan, 2002. AOVET looks forward to bringing you the History of AOVET—The First 40 Years in the form of a booklet with an online version, too. We will keep the AOVET community informed on further interesting developments!
First AOVET Latin American Faculty Training in Brazil, November 2011
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2012 Berton Rahn Prize Winner Esmaiel Jabbari
Esmaiel Jabbari presenting his findings at the Trustees Meeting 2012 in Davos
In-situ Crosslinkable Osteoinductive Poly(Lactide) Scaffold for Bone Regeneration Esmaiel Jabbari, University of South Carolina Chemical Engineering, Columbia, South Carolina, US The overarching goal of this research was to develop engineered matrices to accelerate the process of bone regeneration. While the natural bone regenerative process is biologically optimal, acceleration of the process can reduce the recovery of patients with skeletal defects. An exciting strategy to accelerate bone formation is the use of osteoinductive factors like BMP-2 delivered in a carrier to the regeneration site. However, high doses coupled with the diffusion of the protein away from the intended site of regeneration, and soft tissue compression reduce efficacy and cause undesired side effects such as bone overgrowth, immunological reaction, and tumorigenesis. The collagen sponge packed inside a titanium cage is the most widely used carrier for BMP-2 but the bone density and integration with the host tissue are limited by stress shielding. Bioactive calcium phosphates have also been used as a carrier for BMP-2 but fatigue fracture is a potential drawback. We hypothesized that a carrier that can withstand soft tissue compression and reduce the diffusion of the protein away of the regeneration site will significantly improve BMP-2 efficacy and reduce the side effects of the protein. In an effort to reduce BMP-2 loss by soft tissue compression, we developed a mechanically robust degradable scaffold with well-defined pore geometry. In that regard, a novel poly(lactide fumarate) (PLAF) macromer consisting of short lactide segments functionalized with fumarate groups was synthesized in our laboratory. The salient feature of this macromer is that the short lactide segments allow the macromer to crosslink into a mechanically stable scaffold
Mark Markel awarding the Berton Rahn Prize
while imparting long-term degradability to the scaffold. A rapid prototyping technology was used to produce PLAF scaffolds with well-defined pore geometry. The PLAF scaffolds demonstrated short-term stability against soft tissue compression and long-term degradability. In an effort to reduce BMP-2 loss by diffusion and bone overgrowth, we utilized nanotechnology, specifically the lower mobility of nanoparticles (NPs) than biomolecules, to increase the residence time of the protein in the regeneration site. In that regard, novel degradable poly(lactide-ethylene oxide fumarate) (PLEOF) macromers were synthesized that self-assembled spontaneously in aqueous environment to form NPs with 5-150 nm in size. Next, BMP-2 is chemically attached or grafted to the NPs surface to immobilize the protein on the NPs. The grafting process significantly reduces the diffusion of the protein, thus reducing bone overgrowth outside the regeneration site. Then, the BMP-2 grafted NPs are loaded in porous PLAF scaffold to produce a degradable mechanically stable carrier for BMP-2 delivery with long residence time and extended release of BMP-2 in the intended site of regeneration. The NPs not only immobilize BMP-2 in the regeneration site but they also present a multivalent form of the protein to cell surface receptors, leading to a stronger activation of osteogenic signaling pathways. Bone marrow derived mesenchymal stem cells (MSCs) cultured in osteogenic medium supplemented with BMP-2 grafted NPs expressed significantly higher levels of osteogenic and vasculogenic markers and produced higher extent of mineralization than the medium supplemented with the free ungrafted protein. The findings of this research demonstrate that nanotechnology has the potential to greatly improve efficacy and reduce the harmful side effects associated with the delivery of osteoinductive factors in the intended site of regeneration in orthopedic surgery.
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From the AO Institutes AO Technical Commission (AOTK) In 2012 the TK System has increased its efforts to strengthen the aspect of evidence based development in its activities. As an interface between AO surgeons, engineers, scientists and industrial partners in the management of surgical innovations, development and approval of products and techniques for the treatment of injuries, deformities and diseases of the musculoskeletal system, the AOTKs and their Expert Groups have initiated a new program named “mini registries” to measure the added value of a new technology for patient, surgeons and/or healthcare environments in its workflows.
Meet the Experts at the Davos Courses 2012 After the highly successful introduction of the “TK Innovations: Meet the Experts” at the Davos Courses in 2011, this year’s course participants can visit first hand presentations and hands-on demonstration of surgical techniques based on projects which have recently achieved AOTK approval. These daily lunchtime sessions are hosted by members of the Expert Groups and surgeons with direct involvement in the development processes. Again the three areas of trauma, spine and CMF surgery are covered by dedicated sessions, furthermore special focus areas such as Computer-Assisted surgery and Biomaterials are part of the program as well. Participation is free for all and attendees will not only get firsthand information about the new technology and the clinical basis and application. They will also have the opportunity to discuss with the presenting expert surgeons on site.
TK Innovations magazine Demonstrating detailed descriptions of the latest approved techniques, a new issue of the TK Innovations magazine will be published at the time of the AO Foundation Courses in Davos in December 2012. The latest edition examines 22 new implants and instruments for use in trauma, spine, CMF, and veterinary surgery, with the lead article providing an interesting overview on the Dynamic Locking Screw, developed to address delayed bone healing in distal tibia and femur fractures. Other implants and instruments examined include the LCP Elbow Plating system and the LCP Ulna Osteotomy system, the Proximal Femoral Nail Antirotation (PFNA) Asia, and a wide range of new screws, plates, and power tools for Trauma specialists. For CMF surgeons, the Strut Plate is the newest design for fractures of the condylar process, and for Vets, the new Mini Tibia Leveling Osteotomy Jig helps greatly in orthopedic procedures for small animals. Numerous new Spine instruments are also discussed, including items for degenerative disc disease, implants that protect sensitive vessels during spine surgery, as well as vertebral body replacement devices. Additionally, there is a feature article celebrating 10 years of AOSpine. As always, please contact the publication’s editors for comments and feedback at aotk@aofoundation.org.
Cumhur Onur and Robert McGuire present at a Meet the Experts session during the 2011 Davos Courses
TK System Innovations magazine cover
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From the AO Institutes AO Clinical Investigation and Documentation (AOCID)
may be lengthy and unwieldy in a real-life clinical setting. Automated scoring and reporting is needed in order to utilize the PRO in clinical care. Recent developments in the science of clinical evaluation have made it possible to create computer-adaptive tests (CATs). By harnessing the processing power of computers and applying Item Response Theory (IRT), it is possible to greatly reduce the patient question burden while achieving similar measurement precision.
AO Outcome Center–a powerful new assessment tool in development AO Clinical Investigation and Documentation (AOCID) uses outcomes measures as an integral part of the many clinical studies it conducts in over 300 clinics worldwide. Since the ultimate aim of these studies is improved patient outcomes, it is important to measure the effect of treatment on patients. Traditionally, clinicians have evaluated outcomes using clinical parameters such as range of motion and strength. In recent years, outcome evaluations based on patient self-report (Patient-Reported Outcomes or PROs) have gained in popularity. However, collecting PROs is not easy for many reasons. It involves using questionnaires which
How does CAT work? The test “adapts” to the individual based on the answer to the previous items. The set of asked items differs from person to person, depending on the answers to the previous questions. Unlike static questionnaires to measure patient outcomes, there is no one unique test. A complex computer algorithm creates the subject-specific test by drawing appropriate items from a large item bank (a collection of items). Mark Vrahas, MD, Chairman of the AOCID Committee (pictured on the next page), is the Principal Clinical Investigator behind the AO Foundation’s CAT project. The main objective is to create a webbased software application, the Outcome Center, which will enable a clinician to administer CATs to patients. Instruments appropriate for trauma surgery patients will be included, with a particular focus on upper and lower extremity function. Significant work on this project with multiple funding sources has already been performed. AOCID worked hand in hand with Dr Mark Vrahas and his team from Massachusetts General Hospital, the Assessment Center-Team from Northwestern University, led by Nan Rothrock, PhD, and several other trauma
AO Dialogue 2|12
Traditional paper-based outcome measurement instruments
surgeons. Patient–Reported Outcomes Measurement Information System (PROMISŽ) instruments including CATs are a central feature of the AO Outcome Center instrument library. The default AO outcomes measure assessment battery will include Mobility, Upper Extremity, and Pain Interference CATs. The AO Outcome Center is in development and is currently undergoing quality assurance testing. In the meantime, the working group is adding AO fracture classification content to the module and finalizing the instrument library content.
Mark Vrahas, MD, Chairman of the AOCID Committee
Sometime in the near future in North America, AO surgeons and their patients will be able to take advantage of advances in patient-reported outcome measurement in clinical care with less cumbersome assessment that retains measurement precision. The AO Clinical Study Center program now has its own dedicated website. Visit www.aocsc.org to find out more about this concept to standardize the conduct of clinical research!
The pilot phase of AO Outcome Center is slated to begin in early 2013. In this phase the CATs will be tested with patients and the usability of the application for both patients and clinicians will be assessed by members of the AO Outcome Center team.
Use your Smartphone to scan this code and visit the AOCSC website directly.
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From the AO Institutes AO Research Institute (ARI) At the AO Research Institute Davos (ARI) our mission is excellence in research and concept development within trauma and disorders of the musculoskeletal system and translation of this knowledge to achieve more effective patient care worldwide.
Musculoskeletal Regeneration Program
Using a three-dimensional statistical computer model of the sacrum (in yellow) its anatomical variation is analyzed and compared with the mean shape (in grey)
This program aims to provide innovative tissue engineering and regenerative medicine solutions for the short and long term. The four focus areas of bone regeneration, disc regeneration, stem cells, and polymers and surfaces interact to develop novel combinations of scaffolds, cells and stimuli for the repair of bone, cartilage and intervertebral disc (IVD). Translational and regulatory aspects are always considered when developing therapies to ensure the potential for clinical applicability.
Bone Regeneration Focus Area Due to diverse pathological processes such as trauma, tumor, inflammation and infection, critical sized bone defects (CSD) do not heal spontaneously if left untreated. This constitutes a major challenge for trauma surgeons. This focus area aims to develop biological substitutes, capable of mimicking the natural bone environment, and to improve the functional state of damaged tissue. Therefore, tissue engineering approaches are used to create pre-cellularized and pre-vascularized constructs based on the association of artificial scaffolds (polyurethane) with autologous biological components (cells, growth factors). In parallel, the effect of post-operative mechanical stimulation of such constructs in an orthotopic model on the speed and quality of bone healing are investigated.
Disc Regeneration Focus Area This focus area investigates methods by which MSCs can gain access to IVDs. Two main approaches are under investigation: direct injection
and homing to a damaged disc by way of soluble signals. Investigations have shown that mesenchymal stem cells can differentiate towards the disc cell phenotype when suspended in thermoreversible hyaluronan hydrogel and injected into an IVD ex vivo. Alternatively, recruitment (homing) of mesenchymal stem cells into induced degenerative discs in a whole organ culture system has also been demonstrated. This approach is of particular interest as it does not introduce any new damage to the annulus fibrosus. Work is now underway to identify the signals involved to eventually optimize the endogenous homing repair response.
Stem Cells Focus Area The main goal of this focus area is developing intraoperative solutions for the repair of cartilage and bone. This has involved investigating the potential of mechanical stimulation alone to control stem cell fate decisions. Using a multiaxial load bioreactor it has been shown that human MSCs can be directed towards a chondrogenic phenotype when the correct mechanical stimulation is applied. This opens the possibility for rehabilitation protocols being used to direct and enhance the natural healing response or improve outcomes of cell based therapies. Cell therapies can also be improved by the use of gene therapy. Although viral vectors have safety considerations, these are being overcome, with the European Medicines Agency recently recommending a viral gene therapy for clinical use. This focus area has developed a 3D method that results in protein expression levels which are clinically relevant, can be performed intraoperatively and requires twenty fold less virus than standard protocols, further increasing its safety profile.
AO Dialogue 2|12
Polymers and Surfaces Focus Area Creating innovative bio-functional hyaluronan hydrogels to biomimetically recreate the multiple signals that occur during the normal bone healing process is the purpose of this focus area. It must be capable of inducing rapid vascularization while presenting osteogenic properties. A combination of 1) hyaluronan molecules of different molecular weight and biological activity, with or without functionalization and 2) self-assembling peptides (e.g. RADA-16i) and fibrinogen are prepared. The hypothesis is that the composition of the hydrogel prepared will provide a 3D instructive matrix for encapsulated cells and that the degradation products (hyaluronan and fibrinogen fragments) of the biomaterial can provide biological signals improving angiogenesis and bone healing. The potential of a regenerative approach to CSD healing based on the combination of selected biomaterial with human autologous bone marrow derived MSCs will be evaluated.
Human Morphology Services (HMS) This is a computer laboratory for advanced medical image processing and analysis with a focus on maintaining a database of CT scans and converting them to 3D statistical bone models. Within this scope, HMS members perform research and development projects, and educate medical research fellows. Collaboration between HMS and surgeons of the TK System has been established to assess the anatomical variability of the sacrum in order to help improving fracture fixation in this complex shaped bone. Internal fixation using trans-sacral implants has been advocated for earlier mobilization and pain relief of sacral insufficiency fractures. Surgical treatment
includes positioning of implants through transsacral corridors mainly at the level of the first sacral vertebra. More than 150 pelvic Computer Tomography (CT) scans are currently being processed to generate a 3D statistical model of the sacrum, which will improve understanding of the sacral anatomy, leading to safer implant positioning.
Musculoskeletal Infection Group This group performs research that covers the in vitro investigation of bacterial virulence, the development of antimicrobial delivery vehicles and the development of improved preclinical models of infection. In collaboration with the Polymers and Surfaces focus area, a novel hydrogel designed to deliver antimicrobial agents directly to the surgical or wound site is being developed. Thermoresponsive hydrogels prepared from hyaluronic acid are prepared using a “click chemistry� reaction and these injectable biodegradable materials have been shown to kill even early bacterial biofilms. This technology has great potential in the prevention of infection of open traumatic wounds in particular, which suffer from particularly high infection rates. The flexibility of the hydrogel platform will allow for incorporation of numerous antimicrobials and allow different application mechanisms, including direct application by a spraying mechanism.
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From the AO Institutes AO Education Institute Medical education experts agree that in order to enhance the quality and impact of programs, educational offerings should be based on needs. This new way of thinking moves beyond the traditional measures of participation and satisfaction, to additionally consider clinical performance and patient care. The AO Education Institiute (AOEI) is also committed to conducting educational research and developing new tools in the field of performance improvement (PI).
Performance Improvement (PI) program 3 key steps:
Improving outcomes through performance
AO skills lab
Imaging educational research
1.
AOEI is working to design and develop targeted imaging educational interventions and to measure their impact on key performance and patient care issues.
A training ground for orthopedic and trauma surgeons
Participants assess current practice using selected measures 2. They undertake an educational intervention related to practice issues 3. Participants reassess their practice using the same measures
Funded through an educational grant from Siemens. These projects involve support from colleagues in AO Clinical Investigation and Documentation (AOCID). In 2012, two PI projects started. Daniel Rikli, Michael Blauth, and Samir Mehta with AOTrauma lead a program on intraoperative imaging and Florian Gebhard, Michael Kraus, Bastian Scheiderer, and Bettina Ammann at Ulm University lead a program on the use of MRI in orthopedic trauma.
A hands-on, multi-station work-shop offers an innovative way for surgeons to enhance knowledge of underlying principles and skills of fracture management. Used to gather experimental data for a study on the effect that sharp or blunt instruments have on the performance of experienced and inexperienced surgeons. Results were published in the Journal of Orthopedic Trauma. See list of publications for further information. Addresses four principles of four major orthopedic trauma topics: bone healing, fracture reduction, fracture fixation, and surgical skills. Exercises allow surgeons to get a feeling for a specific technique and improve their skills.
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AO Education Institute essentials Targeting the highest level
AOTrauma: Global Needs Analysis Throughout 2012, AOEI and AOTrauma are gathering detailed information on the individual needs of every surgeon, in every region and country where AOTrauma education is offered. In collaboration with the existing network and local organizations, data will be analyzed and used to plan more relevant and responsive educational activities, better meeting the needs of practicing surgeons. The extensive, quantitative online survey is a major project building on past research in lifelong learning.
In 2010 and 2011, CTC was implemented in more than 20 face-to-face educational courses delivered to 600 practicing trauma and spine surgeons. Analysis of barriers to implementing change also provides information to inform ongoing curriculum development.
3-month follow-up (self-report data) n=12 participants, 14 practice changes
4 Not
3 Fully
implemented
75 patients
Estimated no. of patients who have benefi ted
implemented
Example data
Partially implemented
Topics where change of practice intended
7
Participants: surgeons (36) Surgical techniques, timing, weight bearing, etc.
12
Comanaged care (or some part of teamwork, communication, etc)
10
Commitment to change
Osteoporosis, metabolic bone, Vitamin D
9
A tool for assessing the impact of education on clinical practice
Misc medical/medication issues
8
Develop/QA GF center/program
7
The commitment to change (CTC) practice survey is now integrated in the AO‘s Learning Assessment Toolkit.
Pre/postoperative prep & orders
4
Delirium
3
115 patients
AO Dialogue 2|12
From the President Jaime Quintero talks to AO Dialogue Jaime Quintero, AO Dialogue is published every year to coincide with the AO Foundation Davos Courses, what is the history behind these courses?
The Davos courses have always been innovative. Back in 1960’s when they were established, the courses were innovative because they introduced the concept of workshops, simulating a surgical procedure, and in addition, the AO founding father Maurice E Mueller was a young guy teaching more senior surgeons (this was unheard of at the time). Thanks to the reputation for excellence we have at the AO we have access to the best surgeon faculty and we ensure that they are trained to the highest standards. The fact that our surgeon faculty is comprised of volunteers is unparalleled in the field; these teachers are not AO employees, but rather surgeons imbued with the AO spirit. In the last two decades, once the Davos courses were well-established, the second phase of our education strategy came into play whereby our organization committed to constantly improving the quality, performance and skill of our teachers. This is achieved through educator’s workshops, tips for trainers and faculty education programs. Now we are in the third phase using e-learning and blended learning. We are committed to developing educational offerings that are accessible via mobile devices and online portals. Content can be easily updated ensuring that learners have access to the most current data quickly and easily. Learners are best served when oral, visual and written media are brought together to emphasize key learning points and we want to enhance the learning experience through assimilating video into our educational programs. We are introducing new evaluation methodologies and techniques to get feedback on the quality of our education which we call assessment of educational outcomes and measurement of the transfer to surgical practice. What are the unique benefits for surgeons from around the world of attending the AO Foundation Courses in Davos?
At the 2012 Davos Courses the AO has expanded its education initiative with a new focus on offering more of the relevant education workshops and seminars that meet the specific needs of the surgeons during the 12:00-16:00 afternoon sessions. This new initiative is called: Education Activities for Individual Continuing Professional Development (CPD). Our CPD program is in direct response to feedback we have received from our surgeon network and designed to maximise a surgeon’s time in Davos. The opportunity the AO Davos Courses provide for networking with fellow surgeons and surgeon faculty is second to none. There are membership programs and the chance to meet members of a clinical division. Workshops allow direct interaction with teachers and fellow participants from around the globe. This is the first step in building a network, becoming part of the fraternity. The next step is becoming a member of the relevant clinical division; this is a formal network/fraternity which is an essential part of being a surgeon in these fields.
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