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Biomedical research in schools | Old-timer rally from Beijing to Paris

AO Latin America operations | Prehospital care of equine fracture patients

The magazine for the AO community 1 | 08

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AO Clinical Investigation &

Documentation (AOCID)

The annual audit by SQS went very well, with no complaints

recorded; as a result, renewal of the

ISO9001:2000 has been granted.

The contract with FIDIA, an Italian

biotechnology company, for the

conduct of a Phase II trial has been signed,

with the trial set to start in June 2008. The product under investigation is an

antiscar-forming device used during

spinal surgery.

AO Dialogue 2008

Editor-in-Chief: James F KellamManaging Editor:Elena Grimaud IneichenContributors:Diarmuid De FaoiteEditorial Advisory Board:Jorge E AlonsoJames HunterFrankie LeungRodrigo PesantezPol M RommensPublisher: AO FoundationProduction: AO PublishingDesign and typesetting: nougat.chPrinted by: Bruhin Druck AG, Switzerland

Editorial contact address:

AO FoundationClavadelerstrasse 8CH-7270 Davos PlatzPhone: +41(0)44 200 24 80 Fax: +41(0)44 200 24 21E-mail: [email protected] © 2008 AO Foundation, Switzerland

All rights reserved. Any reproduc-tion, whole or in part, without the publisher’s written consent is pro-hibited. Great care has been taken to maintain the accuracy of the information contained in this publi-cation. However, the publisher, and/or the distributor and/or the editors, and/or the authors cannot be held responsible for errors or any conse-quences arising from the use of the information contained in this publi-cation. Some of the products, names, instruments, treatments, logos, designs, etc. referred to in this publi-cation are also protected by patents and trademarks or by other intel-lectual 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, instru-ment, etc. without designation as proprietary is not to be construed as a representation by the publisher that is in the public domain.

AO Research Institute(ARI)

The surface of any implant influences

the body’s response to it. In vivo tests

show that polishing titanium cortical screws reduces removal torque.

Other tests regarding bony in-growth onto intramedullary (IM)

nails showed that polishing significantly

reduced the extraction force required for

titanium alloy (TAN) IM nail removal. As

TAN is preferred over stainless steel

for IM nailing, due to its better biocompatibility and mechanical

properties, these results can be used to recommend changes

to current surface characteristics of IM

nails. This should reduce complications

seen with nail removal, especially

with rapidly growing bone in pediatrics.

AO Development (ADI)

Due to AOVA’s decision of December

2007, an R&D Competence Center

will be created by combining the

existing AO Research Institute (ARI) and AO Development Institute

(ADI).

The first steps to establish the AO R&D

Competence Center will be taken through

workshops and task forces. Participants

drawn from all levels of the ARI and ADI

hierarchy will be invited to take part.

Current and future project work will be analyzed and

developed during the design process

throughout 2008. The complete changeover

is planned for 2009.

From the AO Institutes

AO Education (AOE)

A record number of 17 courses

were successfully completed in Davos

in 2007. Course evaluations showed a

small but significant improvement in the

quality of education, as assessed by course

participants.

Education plans for 2008 show an increase in course

days of 16%, with the largest increase in

education occurring in Asia-Pacific. Much

of this is due to the growing number of

specialty courses, reflecting the needs

of course participants on a worldwide basis. Achieving

our education goals within necessary

budgetary constraints will be the challenge

for 2008.

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Table of contents

10

6

36

12

community zone

Panorama

4–7 News & Events8–9 People

Report

10 Taking biomedical research to schools

12 Old-timer rally from Beijing to Paris

Inside AO

18 The AO’s 50th anniversary celebration

From the regions

22 AO Latin America

Internet

25 AO Portal redesign

expert zone

Clinical topic

Minimally invasive osteosynthesis 26

MIPO of the humeral shaft 27

Percutaneous fixation of pelvic and acetabular fractures 30

MIPO in the lower extremity: a Latin American perspective 34

AO Vet news Prehospital care of equine fracture patients 36

James F KellamEditor-in-Chief

[email protected]

On March 28, 2008, Maurice Müller unveiled a plaque commemorating the AO’s first 50 years at the Hotel Elite in Biel, Switzerland, where the AO was founded. Maurice Müller had a vision, and together with twelve other inno-vative Swiss surgeons, he provided a platform to allow interested, inventive and collaborative people the opportu-nity to build upon his ideas. This was not limited to orthopedics and fracture surgery, but to all aspects of life.This issue of AO Dialogue shows how the AO and those involved with the Foundation continue to promote the founders’ concepts. Markus Rauh, chairman of the AO Board of Directors, was instrumental in the reenactment of the 1907 Peking-to-Paris car rally last year, showing how one individual with an idea can bring people together to accomplish a goal. AO Research Fund prize winner Karen Burg has a mission to open the imaginations of young people to scientific method. She discusses taking science and its atten-dant excitement to the classrooms of elementary and high school students. In the Expert Zone, Rodrigo Pesantez has put together several articles by in-novators in the newer techniques of minimally invasive fracture surgery, who discuss its use with humeral shaft fractures, and look at different options around the pelvis, acetabulum, and the lower extremity. These diverse articles show how our founders created an or-ganization that provides a platform for individuals to be creative, innovative, and most significant, to add something important to others’ lives.

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AO Italy courses held in Davos The Congress Center in Davos in February 2008 wel-comed Italian surgeons taking part in three courses organized by AO Italy, includ-ing the AO Principles Course (Base) and the AO Advances Course (Avanzato), each of which attracted 72 participants and a handful of invited observers. Forty partici-pants attended an additional course, AO Comprehensive sul ginocchio—a comprehensive course focusing on the knee. Innovations this year included a joint session for all three courses to help foster communication between the groups, an imaging workshop fea-turing state-of-the-art technology, and follow-up discussions, all of which were well-appreciated. “The courses offered are based upon the needs of Italian surgeons and there is certainly great demand for AO courses in Italy,” says AO Italy Education Board Faculty Member Nicola Annicchiarico.

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Two-day celebrations in Kobe, Japan to commemorate the 20th anniver-sary of AO courses in Japan, the 10th anniversary of the AOAA Japan Chapter, and the AO’s 50th anniver-sary, began with a memorial party on Saturday, February 23, 2008, and closed with a memorial lecture the following morning. The first AO course in Japan was held in 1987 and for the next ten years courses were conducted mainly by foreign faculty and professors with Japanese universities. With the formal inau-guration of the AOAA Japan chapter in October 1998, this changed and today, the chapter’s 240 members are involved in AO courses, semi-nars, translation of AO books, clini-

cal research, and web page updates. Reflecting on AO Japan’s 20-year-history, as well as the next 50 years, celebrants appreciated the important role the AO Foundation has played and will continue to play in terms of improved trauma care, daily clinical practice, and research and develop-ment in Japan.

World Forum for Spine Research The World Forum for Spine Research, held at end-Janu-ary 2008 in Kyoto, Japan, was a great success and a fitting start to the AO Foundation’s 50th anniversary celebrations. The AO Foundation and AOSpine were two of the major sponsors of this high-caliber meeting of clinicians, biol-ogists, engineers and scientists, which received excellent reviews, not only from participants, but also from faculty members. It consisted of lectures by faculty, invited talks, short poster talks, and general poster presentations. The young age of many of the participants was no-ticeable and may have contributed to the high levels of enthusiasm and motivation that were much in evidence. With just over 200 scientific participants from 32 countries, this was a truly international gathering of experts, and clearly demonstrated the value of such meetings.

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AO SEC trauma symposium in Nepal The Orthope-dic & Trauma Foundation, Nepal, hosted a two-day trauma symposium on nonoperative fracture treat-ment from January 11 to 12, 2008, at Janakpurd-ham. This program was sponsored by the Socio Eco-nomic Committee (SEC) of the AO Foundation and for the second time took place in Nepal. Forty-six participants and four faculty members took part. The main objective was to make young trauma surgeons and general medical doctors in Nepal aware of the “Principles and Practice of Nonoperative Fracture Management” through presentations, demonstra-tions, discussions, and hands-on workshops. Local problems were discussed at length with an emphasis on local adaptations, and a special session on close management of common fractures with plaster and traction application was held. Problem-based learn-ing and evidence-based teaching are the two prongs of this educational program specially designed for underfinanced and developing countries.

CMF symposium celebrations in Utah On the occasion of the annual advanced craniomaxillo-facial symposium at Snowbird, Utah, from February 22 to 24, 2008, AO CMF NA (North Amer-ica) and AO CMF LAT (Latin America) joined together to celebrate the AO’s 50th anniversary. The theme of the advanced symposium was CMF surgery in the age extremes (pediatrics and ge-riatrics). Up for discussion were a number of topics dealing with the intricate nature of operating on these two age populations. The keynote lecture was delivered by Joseph Gruss, pioneer in the treatment of craniomaxillofacial fractures and congenital deformities in children and long time AO CMF faculty member. The symposium’s highlight was the reception organized by AONA to celebrate the AO’s 50th anniversary. The event was attended by symposium participants as well as by a number of AONA medical education key personnel and AO CMF NA faculty members.

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Geriatric Fracture Management course in Hong Kong The Hong Kong AO Alumni chapter held the first AO course in geriatric fracture management in Asia. Through the leader-ship of course chairman Frankie Leung, a comprehensive scientific program and practical exercises for state-of-the-art fragility fracture fixation methods were conducted during the three-day program. Distinguished faculty including Michael Blauth, Stephen Kates, Robert McCann and AOTAP old guards Suthorn Bavonratanavech and G On Tong shared their experi-ence in fracture management of fragility fractures with the 45 course participants, who realized they share common issues and problems in effecting the ideal clinical pathway, notwith-standing the difference in geographical regions. The recently launched “hip fracture surgery clinical pathway” presented by TW Lau was commended for taking the first step of starting such a program in Hong Kong. Participants will return to their respective practices and lead their colleagues in the formula-tion of health policies to improve geriatric fracture care man-agement, something which should be a co-managed program.

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Medical students at the AO Center Two courses for medical students from five differ-ent Swiss universities took place in January 2008 at the AO Center in Davos, Switzer-land. For the first time since these annual courses began more than 30 years ago, they were given in French and in German. Over 80 students from Lausanne and Geneva participated in the French-language course on January 16 and 17, 2008, while the German-language course held on January 18 and 19 welcomed 144 students. Elyazid Mouhsine, Volker Braunstein, and Christian Ryf supervised the ever-popular practi-cal exercises in operating techniques using synthetic bone models. Students learned of new developments in the AO Foundation, in research, and about the multi-award-winning online reference website, the AO Surgery Reference. Lectures on develop-ments in the most common winter sports injuries over the past 30 years, and on rescue operations in the Parsenn ski region completed the course.

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AO North America has been granted reaccreditation for four more years until March 2012 by the Accreditation Council for Continuing Medical Education. AONA was evaluated and found in compliance with all criteria from its purpose and mission, educational planning and evaluation processes, administration, standards for commercial support, to its ac-creditation policies. It received exemplary compliance for consistent use of multiple sources of needs assessment data to plan continuing medical education activities. The reac-creditation reaffirms AONA’s mission to improve patient care through education and research in the principles, practice, and results of treatment. AONA has also been reviewed and approved by the American Association of Veterinary State Boards as a Registry of Approved Continuing Education pro-vider for veterinarians through to February 2010.

AOSpine’s new membership concept Since December 9, 2007, AOSpine has operated a subscription service for members offering three packages—Basic, Classic, and Professional, each with a selection of benefits to suit dif-ferent needs. In addition to their chosen benefits, members receive hard copies of AOSpine journals, eg, the new members’ magazine, “myAOSpine”. eMembers pay a reduced fee and can download these journals in electronic format only. AOSpine follows a simple, transparent system of member progression regardless of the package cho-sen: Bronze, Silver, Gold, and Platinum. Every position or activity within AOSpine is assigned a defined points value. You earn your points by contributing to AOSpine. Subscribing members who get involved in the AOSpine community are entitled to further privileges, rewards, and exclusive offers. To join, go to www.aospine.org and click on the link: Apply for membership. Subscriptions go directly back into benefits. As membership grows, AOSpine will be able to leverage funds into delivering increased and more varied benefits for its members.

The AO Educators’ Seminar for ORP, from December 9 to 14, 2007, in Davos, provided an excellent op-portunity for course participants to improve pro-fessional skills relevant to their everyday work. The seminar focused on “Teaching and Learning” and “Leading and Organization” and subjects proved “an inspiration to my work in the theatre and education,” says participant Forcina Mdala of Malawi. “I learned more about giving a lecture, leading discussion groups and running a practi-cal exercise. My confidence is enhanced due to the knowledge and skills I acquired.” Interacting with colleagues from other countries “gave us the chance to exchange experiences about our daily professional lives…and has motivated me to reach out to ORP nurses in other hospitals,” she says. Cristina Mariscal of Spain appreciates that: “Ev-eryone in the group wanted to help each other. I met wonderful people, faculty and participants and learned so many useful things. I will never forget this week.”

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AOLAT honorary memberships awarded On December 12, 2007, AOLAT paid tribute to Erich Schneider, Jesse B Jupiter, and Esther Stoop to demonstrate AOLAT’s gratitude for the outstanding contributions the three have made to the region’s development and evolution. Erich Schneider and Jesse Jupiter received from Jaime Quintero, on behalf of Carlos Sancineto and AOLAT, a diploma naming them as honorary members of AOLAT. Esther Stoop has been instrumental in developing the AO Alumni Association (AOAA) all over Latin America. Jesse Jupiter has been to almost every country south of Mexico to teach different techniques in trauma and upper extremity surgery and many Latin American surgeons have visited him at Massachusetts General Hospital in Boston as AO fellows and visiting professors. Erich Schneider has helped AOLAT take its first steps in basic research and at the last AOAA meeting in Cancún, Mexico, both he and Beate Hanson taught members how to assemble a “Road to Research Map” in basic and clinical investigation.

A Tribute to Berton Rahn On March 26, 2008, Berton A Rahn finally found release from a long and difficult illness. Berton studied dentistry and medicine in Zurich and Berlin. In 1968 he joined the Laboratory for Experimental Surgery in Davos, a group whose future was uncertain, as the AO Re-search Institute then had secure funding for only a few months. He stayed for 37 years.Berton studied oral surgery and he made important contributions to the development of craniomax-illofacial surgery as well as dental implantology. He also was interested in the microscopic anatomy (histology) of bone healing and developed polychrome sequence labeling for newly formed bone, today used worldwide in bone research. He also looked at the chemical stimulation of bone healing, which in conjunction with the treatment of bone loss (osteoporosis), is currently receiving a lot of attention. His research was characterized by its scientific creativity, and particularly by the support he offered to young researchers. Berton was also vice-director of the AO Research Institute and in his retirement served as Scientific Advisor to AO research. We have lost a quiet man of depth; we regret he could not enjoy the fruits of his labors for a longer time. His many scientific contributions to journals and books will outlast him.

Dedication to both patients and medical staff: Cathy Connolly The Australian and internation-al nursing communities are mourning the loss of a valued mentor, colleague and friend with the death due to cancer of Cathy Connolly, aged 42, on September 24, 2007. Cathy participated in the AO ORP basic course in Sydney, Australia, in 2000 and her enthusiasm to teach and men-tor lead to her being invited to the ORP Educa-tors’ Seminar later that year. An active faculty member, in 2002 she took part in the formation of the ORP Alumni Chapter, welcomed into the AOAA during the Davos courses that year. In 2003, Cathy was appointed the first chairperson of the executive committee of the ORP Alumni. Ever active in the Australian AO community, she was named a director for AO Oceania in 2005. In her free time, Cathy volunteered for an ortho-pedic outreach program providing treatment for the underprivileged. Cathy is remembered for her dedication to both patients and medical staff and for her natural skills at mentoring younger nurs-es, inspiring them with her passion for orthopedic trauma surgery.

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Paula SoteloCompleted a fellowship in Clinical Investigation and Documentation at AOCID, Dübendorf.

A fellowship is beyond learning techniques or aptitudes, it broadens our views, experience and world in order that we become better doctors. Being a young orthopedic surgeon involved for some years in the hand surgery field, I needed concepts on clinical investigation. The AOCID fellowship offered all that I was searching for.I learned new concepts and investigation tech-niques, but it was even more than that. It was tutoring by people with great experience in clini-cal investigation sharing their knowledge and know-how in a friendly and open manner. The friendships established, new concepts I learned, and being involved from the first day in up-to-date clinical investigation techniques were more than just “learning experiences”–they were life changing.

Having these mentors-friends is the most powerful tool the AOCID fellow-ship gave me. Even though I am no longer their fellow, they continue to encourage, teach and help me. This has allowed me to develop a new branch in my practice, not only for myself, but to share with colleagues at my hospital and with orthopedic surgeons in Latin America. A career and life learning ex-perience, with mentors-friends made along the way.

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TK Awards 2007 The Technical Commissions and Specialty Expert Groups (comprising the TK-System) gave their highest accolade, the TK Innovation Prize 2007, to two Japanese surgeons. Takeshi Sawaguchi was recognized for his numerous contributions to developments in the distal tibia and foot, as well as adaptations of existing implants to the Asian anatomy. Toru Sato also received the prize for his numerous con-tributions to developments in intramedullary nailing and adaptations of existing implants to the Asian anatomy. Peter Messmer, from Basel, Switzerland, was honored with the TK Certificate of Merit 2007, for his outstanding contributions to the development of the co-axial clamp.

Joseph Schatzker honored AO Foundation Past-President Joseph Schatzker has received the high-est distinction awarded to Ca-nadian citizens, the Order of Canada, in recognition of his contributions to orthopedic sur-gery, particularly for introduc-ing surgical procedures for the internal fixation of fractures to North American surgeons. The Right Honorable Michaëlle Jean, Governor General of Canada, announced the appointment of Professor Schatzker, of Toronto, on December 29, 2007.

Paula Sotelo, MDHospital del TrabajadorSantiago, Chile

[email protected]

Upper row, (left to right): Andreas Fäh, Theddy Slongo, Laurent Audige, Jim Kellam, Bottom row, (left to right): Isabel Diterich, Paula Sotelo,

Jannicke Juchli, and Michael Weninger.

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I first learned about the amazing world (no bias) of biomedical engineering when I was 17 and considering “what I wanted to be when I grew up.” The discovery was completely by happen-stance: a good friend of mine relayed to me her ambition to be a designer of biomedical implants and systems—hips, hearts, and knees. What an exciting concept! Her enthusiasm for this career was contagious and I subsequently focused my

goals on obtaining engineering degrees, then working as a research fellow at a medical center, and eventually obtaining a faculty position and building a research program in engineered tis-sues. I feel enormously fortunate to have stum-bled into this line of work, however, I also feel that students should not have to stumble into ca-reers and should have more awareness of science, engineering, and medical careers at an earlier

So, what do you want to be when you grow up?

An AO Research Fund Prize winner takes biomedical research to schools

Karen BurgDepartment of BioengineeringClemson UniversityClemson, South Carolina, US

[email protected]

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age than I did. I feel that we who are in the field of medical research should be proactive in ensur-ing that students have every opportunity to learn about our field. I have attempted to respond to this obligation by integrating an outreach com-ponent into my research activities.

The issue is knowledgeMy overarching goal is to assist in creating in-formed individuals with an understanding of biomedicine and the role it plays in their lives; my expectation is not to convert the world’s children to clinicians and biomedical researchers. Will I be ecstatic if our efforts convince a few kids to become bioengineers or physicians? Absolutely! However, the larger issue at stake is knowledge, access to that knowledge, and the effect on public policy. There are so many medical policies that are defined with input from the public. An un-informed public means an uninformed decision-making process. I believe that we want our chil-dren to become critical thinkers, able to observe, listen, synthesize, and act accordingly.

Seeing and learningMy specific outreach activities center on commu-nity engagement projects with particular focus on injecting the school system with biomedical/bioengineering concepts and ideas. The AO Re-search Grant is one of several grants that have

produced content that has been translated into a classroom set-ting. The concept is simple: I work with a team of my gradu-ate students in distilling com-plicated research topics (like the development of bone graft for critical size defects) into simple, “real world” words and laboratory demonstrations that a seven-year-old or a 15-year-old or a stranger on the street could understand. We gather household items to simulate

medical problems and repairs (crafting beads for bone cells, fabric for a skin graft, etc), but we also collect actual medical devices (knees, hips, bone graft, reamers, etc) from hospitals and biomedi-cal companies so that students can see and learn about the actual device—the clinical need, the design process, the clinical process, etc—while experiencing some of the concepts by working with household items to simulate biomedical/

bioengineering concepts and ideas. This process also teaches our graduate students how to be better communicators (try explaining the bone defect repair process to a friend with a non-sci-entific/medical background, then try explaining it to a seven-year-old—communication is such a difficult, but crucial skill). It is our responsibility to educate others in what we do. It is, in fact, in our own best interest to do so. Additionally, it’s downright fun!

Sharing biomedical knowledgeClemson University, a public, land-grant insti-tution with a very defined educational mission to the southeastern region of the United States, endorses “service learning,” where university courses may be specifically designed to incorpo-rate a community engagement project. In these projects the students receive formalized oppor-tunities to experience the connection between their own studies and the community. I have used this framework in three ways: teaching teachers, creating learning modules, and hosting on-site learning tours. Our interest is in reach-ing schoolchildren and so our activities are also directed towards individuals who teach these children. Accordingly, we teach a biomedical course annually at the Museum of Science in Boston and we have partnered with the Howard Hughes Medical Institute to teach introductory biomedical courses at Clemson University to sci-ence teachers.

Rewards are enormousWe have recently developed a new program where graduate student researchers work with education graduate students to help produce course content that the education students can use in their student teaching. We have published biomedical modules in magazines that are spe-cific to teachers. We also host tours and school groups biannually. I have never encountered a group of schoolchildren or schoolteachers that was not extremely enthusiastic about the topic of biomedicine. The reward is enormous and is seen in the faces of children who realize for the first time they can be problem solvers and they do have valuable opinions. I express my sincere gratitude to the AO Foundation leadership for caring about the future of biomedicine and for giving my graduate students and me the oppor-tunity to leverage our research grant into a series of biomedical experiences for schoolchildren.

1 Karen Burg receives the 2006 AO Research Fund

Prize Award from Fund Chairman Adrian Sugar.

2 Karen Burg (left) and Clemson University

graduate students Cheryl Gomillion and Cheryl

Parzel at a workshop for teachers at the Boston

Museum of Science.

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Markus RauhChairman, AO Board of DirectorsDavos, Switzerland

[email protected]

During a break in a business meeting in March 2005, Urs Ramsauer, an old friend of mine, com-plained to me about the frustration of his divorce. I tried to cheer him up and encouraged him to do something ‘crazy’ to help him forget his problems. All of a sudden his eyes started to glow and he said, “I’ll drive with my old-timer Ford V8 Sahara 1947 from Peking to Paris!” Not hesitating for a second, I replied, “Urs, if that is not a joke and if you orga-nize it, I’ll join you!” That moment was the begin-ning of a great adventure. Urs is an old-timer-au-tomobile fan and I am anything but that—I didn’t even have an old-timer car and had never partici-pated in a rally. But the idea of doing something like this fascinated me so much that even my wife Brigitte recognized there was no discouraging me from undertaking this adventure.

Only days later, I found out the reason Urs had proposed the Peking to Paris route: to mark the centenary of one of the greatest adventures in

the history of automobiles—the Peking-Paris Raid, a 14,000-km drive across the Gobi Desert and Siberia.

In March 1907, the French newspaper “Le Matin” published a challenge to motoring en-thusiasts to race from Peking (now Beijing) to Paris, an unthinkable endeavour given the au-tomobiles and roads of the time. All of Europe was betting on whether or not it could be done. On June 10, 1907, five teams started the race at the Doschmen Gate of the Great Wall, north of Peking (incidentally, where the “Dinner on the Great Wall” took place during the last AO Trust-ees meeting in June 2007).

Count Scipione Borghese won the race in 60 days with his Itala, a predecessor of today’s Fiat, arriving in Paris on August 10, 1907, a full two weeks before the second place Spyker. Borghese was accompanied by a journalist who regularly

Old-timer rally from Beijing to ParisAn unforgettable experience

1 AOVA Chairman Markus Rauh (left), teammate

David Hove, and Rauh’s wife Brigitte celebrate the rally’s successful finish in

Paris, August 2007.

2 A 40 m-high monument to Genghis Kahn outside

Ulaanbaatar.

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telegraphed dramatic progress reports to Italian and French newspapers so that millions of fans could feverishly follow the race. A book published afterwards featuring many race photographs became a bestseller and was translated into 21 languages. But then came the First World War and this great adventure sank into oblivion.

Recreating a daring adventureUrs and I decided to organize a commemorative rally, not a race, but a well-organized event for friends who would assist each other in overcoming the hurdles on the long journey from Peking to Paris. It would commence on the same de-parture date, end on the same arrival dates, and more or less follow the same route as the original rally, knowing that with today’s roads and support infrastructure we could devote al-most 20 of the 62 race days to visiting places of cultural and historical interest. So far as the old-time cars were concerned, they would be at least 40 years old.

Thanks to word of mouth, a group of 30 teams finally came together. The participants, who did not know each other be-

forehand, were predominantly Swiss and from totally diverse backgrounds. We had a broad variety of cars, ranging from a 1907 Spyker (identical to the runner-up in the original race) to a 1960 Willys Jeep. Among us were 46 men and 17 women, aged between 50 and 70 years. I motivated my brother-in-law, a retired teacher and a longstanding old-timer hobbyist to pre-pare a Ford V8 1938 convertible as our vehicle. He took care of the mechanics and I took charge of administration.

Our cars were shipped in containers (almost free of charge because of the lack of cargo from Europe to China) from Basel to Tianjin. On June 10, 2007, one day after the close of the AO Trustees meeting, we began our journey at the Doschmen Gate with an impressive ceremony organized by a Chinese TV chain. In 42 stages we drove more than 14,000 kilometers through China, Mongolia, Russia, the Baltic States, Poland, Germany and finally into Paris, where we had a great wel-come party at the Place Vendôme on August 10, 2007.

Overcoming unexpected obstaclesWe had so many adventures and enduring impressions that a full report is impossible, but I will summarize a few highlights. During our extensive preparations we were warned about the lack of a proper infrastructure to provide us with quality fuel, water, repair facilities, communications and money. The pos-sibility of heavy rainfall (as Borghese had experienced) also concerned us. But in these respects we had no problems at all.

The infrastructure was much better than expected. For ex-ample, I was able to call my wife using a normal GSM (mobile) phone every day except for five in the Gobi Desert, when I needed my Iridium phone. The phone bill, however, was more than CHF 5,000! We were very fortunate with the weather, having excellent conditions all the way to Berlin. We were also warned about the dangers of crime, but we did not expe-rience a single negative incident, although we came to realize there was very little respect for private property—a legacy of communism. People both young and old did not hesitate to sit (without asking) on our parked cars in order to take photos and have fun.

We innocently assumed that our old-timers (which had so far been used only for concours d’élégance) could withstand the challenge of the terrible roads in Mongolia and Siberia and so we did not take a repair vehicle with us. This was totally naïve as almost all the teams were plagued by severe technical problems. Minor repair jobs could be handled by car mechan-ics in our group or at one of the many Toyota garages along the route. The availability of spare parts, however, remained a major logistical nightmare. In the middle of Siberia, our transmission broke and could not be repaired. Thanks to per-sonal connections we were able to find a replacement in Am-

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sterdam. This was the easy part—getting it to Yekaterinburg within 36 hours was the challenge, as this could only be done by couriers with Russian visas and knowledge of how to get through Russian customs (with lying, cheating and bribing). Nobody believed it could happen, but wonder of wonders, it did. Thanks to the tremendous commitment of the very quali-fied specialists at the Toyota garage we were able to join the group leaving Yekaterinburg.

Memories to last a lifetimeThe Gobi Desert is the world’s biggest, with no roads—and no maps available to help chart our path across it. To do so you need a guide: unfortunately ours was totally drunk and lost his orientation. We drove in circles on terrible terrain. At midnight we camped where we were, completely lost in the desert. Some drivers slept in their cars, others, like us, on the sand covered with whatever we had. It was very cold at night, but thanks to the new moon we had the most wonderful ex-perience, seeing millions of stars in the totally black sky. My

115° of latitude in 2 months.

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3 Driving in the last sunbeams before a cold

Gobi Desert night.

4 The author’s Ford V8 1938 being fitted with a new transmission in

Yekaterinburg.

memory of that night is almost mythic and now I know why the Milky Way bears its name.

Mongolia has a dramatic history. In the 13th cen-tury, Genghis Kahn ruled it, the largest empire in world history, from his capital, Karakorum. Today nothing is left of that culture, the Chi-nese and Russians having destroyed it. Since the breakdown of the Soviet Union, Mongolia has become independent and its populace is desper-

ate to develop a new national identity. They are basing it on Genghis Kahn, who is omnipresent and praised like a godfather. As part of an official welcome party in the capital of Ulaanbaatar, we all had to walk up a red-carpeted stairway to a gigantic statue of the historic ruler, before which we were expected to bow for at least one minute. Walking up the stairs I pleaded with myself not to do it, but standing there under the eyes of our hosts, the military commanders, I relented.

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Witnessing Siberia’s rebirthThe revival of Christianity in Si-beria is an unexpected and unbe-lievable surprise. In every major city, magnificent churches and monasteries destroyed by the com-munists during the revolution are being rebuilt to look exactly as they originally did. But before begin-ning reconstruction, the sites have to be excavated from factories and other buildings the Soviets built to cover up the past with the intent of erasing people’s memories. The new churches hold services every day and are full–not only with el-derly women, but also with many youngsters and especially, men. On weekends, Russia and the Baltic

States are full of glamorous weddings with wonderful brides and grooms and millions of rose petals.

We experienced all kinds of accommodation, from tents to “jurte” camps, from old, run-down Soviet sanatoriums to all classes of hotel. The reception was mostly friendly with the ex-ception of the luxury hotels in big Russian cities, where they ripped off their foreign guests with exorbitant prices, like beer for USD 20 and cleaning a pair of underwear for USD 10.

All in all, recreating the Peking-Paris Rally was the greatest experience of my life (and Urs forgot all about his divorce)—but would I do it again? Clearly, no! The safety risks we took on the unbelievably dangerous roads in Russia were so tre-mendous that we have to thank God we all safely made it to the end. To repeat the experience with the same cars (with pre-Second World War safety standards) would be to gamble with our lives.

5 Moscow’s Red Square: 9,934 km and two-thirds

into the rally.

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Tim PohlemannMember, AO Board of DirectorsHomburg-Saar, Germany

[email protected]

After ten years as director of the AO Research Institute (ARI), Erich Schneider left the post on January 31, 2008, to take up new challenges. Erich Schneider was born in Wettingen, canton Aargau, and studied at the renowned Swiss Fed-eral Institute of Technology (ETH Zürich) from 1969 to 1974, then at its Institute of Electrical Equipment Design (1975–1976), before switch-ing to the Biomechanics Laboratory under Jürg Wartenweiler and Benno Nigg (1976–1980) to complete his dissertation.

After a research fellowship at the Biomechanical Laboratory, Depart-ment of Orthopedics at the Mayo Clinic in Rochester, New York, US, under Edmund Chao (1980–1982), he was appointed research associ-ate and vice-director of the Maurice Müller Institute for Biomechanics, University of Bern, directed by Ste-fan Perren from 1982 to 1988, with interim lead until 1989. During this period, several fundamental proj-ects were accomplished, including the inauguration of a spine simu-lator, motion analyses after pelvic fractures, primary stability of end prosthetic components, 3-D imag-ing and intravital force monitoring after femoral nailing.

Elected chairman of the renowned Institute for Biomechanics at Hamburg-Harburg Technical University, Erich and his family moved to north-ern Germany in 1990. In 1997, the chance to once again enjoy Swiss mountain culture came when he was appointed director of the AO Re-search Institute in Davos.

Over the past ten years the Institute went through major structural changes and widened the spec-trum from biomechanics and bone pathology to a full-scale “bone-and-cell-biology research unit” focusing on the mechanisms of bone and cell

healing, tissue engineering, imaging and transla-tional research. In addition to his many respon-sibilities with the AO Foundation, Erich taught at the University of Bern and ETH Zürich and held a travelling professorship with the Rush-Presbyte-rian-St.Luke’s Medical Center in Chicago. He has published more than 132 original articles in well-known journals, 80 book chapters, 400 abstracts and presentations.

Erich Schneider was a caring mentor and friend to many of us and later to our residents and fel-lows. Thanks to him, a huge group of young sur-geons were lead through their first steps in basic and applied science, and experienced the fascina-tion of interpreting sound scientific results after proper experiment planning and execution.

Erich Schneider has been honored with many renowned awards including the Walter Brendel Award in 1999, the Ferdinand Sauerbruch Award in 2002, the Osteology Travel Award in the same year, the Arthur Vick Prize in 2005, and the Dief-fenbach Büste of the German Trauma Society in 2006, to mention only a few.

I want to thank him for all he has given to our medical community and to the AO and wish him the very best in his future professional achieve-ments and private endeavors.

Erich Schneider — “a caring mentor and friend”

AO Research Institute director leaves to take up new challenges

Erich Schneider (far right) with his wife, Dorothee, and members of the

“AO Family”, in Venice for the 2004 AO Trustees Meeting.

take up new challenges

Thanks to him, a huge group of young surgeons

were lead through their first steps in science.

Erich Schneider

17community zone Inside AO


Fifty years ago the AO was founded by a group of 13 visionary surgeons in Biel in Switzerland. These ‘founding fathers’ came together to create ideas and technology to improve patient care in the field of traumatology and diseases of the mus-culoskeletal system. Their success truly trans-formed surgery, changing lives.

Today’s AO wants to pay tribute to these pio-neers. Throughout 2008, the AO is celebrating

Diarmuid De FaoiteEditor, AO Communications & Events

[email protected]

the achievements of its founders, and those who later carried the torch, in a fitting manner with a variety of events.

Exciting array of international eventsTo help ensure this will be a memorable year, a 50th Anniversary Steering Board began working on the celebration at the end of 2005. Many ex-citing activities have been planned all over the globe. Some of these are annual events, with a

As AO President Chris van der Werken applauds (left), Maurice E Müller, an AO founding father, unveils a commemorative plaque marking the AO’s 50th Anniversary at the Hotel Elite in Biel.

Transforming Surgery—Changing Lives

The AO’s 50th anniversary celebrations

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special touch of the 50th anniversary theme, and others are unique events developed just for the celebration.

The opening ceremony was performed at the AO Davos Courses in December 2007, where the spe-cial jubilee logo was unveiled. A series of sympo-sia will be staged at congresses and AO Alumni events and regional courses throughout the whole of 2008.

On the occasion of his 90th birthday, Friday, March 28, 2008, Maurice Müller, an AO found-ing father, unveiled a commemorative plaque at the Hotel Elite in Biel, where the AO was founded. A meeting of the Board of Directors and Academic Council also took place there the same weekend. The Jubilee Trustees Meeting will be held in Davos in June, where a special car-free evening in the town will help cement the AO’s special re-lationship with the townsfolk of Davos.

Being sent as a young resident in 1985 to the Jubilee AO Davos Course by Harald Tscherne, I was deeply impressed by a perfect course organization and for me up until that point, an unseen level of didactics, presentations, and practical exercises.However, when asked to remember specific details I was mostly impressed by three circumstances:

1. Being able to get a photograph showing Maurice Müller together with me and my colleagues (see below).

2. Riding uphill together with Martin Allgöwer in the same compartment on the Parsenn ski trail. Martin wore a bobble cap and talked with us about skiing techniques.

3. Having received a Swiss watch as a present on the occasion of the Jubilee AO Davos Course, I entered the Davos swimming pool thanks to a sponsored sports ticket with about 25 fellow participants to check the water resistance of the watch in a practical experiment...the watch turned out to be completely waterproof and is still in perfect shape today! Tim Pohlemann

From right to left: Tim Pohlemann, Philipp Lobenhoffer, Norbert Südkamp and Maurice Müller, with fellow Davos course participants.



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The AO Alumni Association is contributing to the celebrations by replacing their triennial event with three events to be held in Greece, Thailand, and the United Arab Emirates.

Amirah Blackmore is the Anniversary Manager based in Switzerland with responsibility for co-ordinating the celebrations around the world. “The jubilee year will be a celebration of the past while looking forward to the future. This is re-flected in the slogan to be used throughout 2008 which is: the first 50 years. This wording ensures that the AO is seen as a forward-looking organi-zation.”

Special website keeps members up to dateA special anniversary website has been commis-sioned and is the best method to keep up to date with the many events related to the celebrations. It can be viewed at www.aofoundation.org/an-niversary or by following the link from the AO’s home page. Content is being added all the time as events happen so it is advisable to check back frequently over the course of the year.

While the focus within the AO quite rightly is on the scientific aspects, the anniversary celebrations are a unique opportunity to highlight the role interpersonal relationships have played over the

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How to access the TK-System

The AO appreciates feedback on existing in-struments and implants and welcomes input to solve unmet clinical needs. New ideas are introduced to the System of Technical Com-missions (TK-System), in which over 120 highly specialized surgeons from around the world work on new solutions. They form Expert Groups in the respective areas of medical specialty, which are professionally supported by teams of engineers, research-ers and other specialists from the AO and its commercial partners.

To initiate discussion of new ideas, we ask for a description of the clinical problem being addressed and for suggestions on how to approach it. Technical drawings and first prototypes are made according to the pro-posal and presented to the specialists; to-gether with them, the proposal’s potential is evaluated and improvements and alternative approaches are discussed.

If the submitter’s innovation is successfully completed, they will be involved as a faculty member in AO teaching activities that en-sure proper training of the new device. The overall process is described on the AO web-site at www.aofoundation.org (see AO in-depth; Activities; AOTK; Expert Groups). Ideas may be proposed via e-mail at [email protected] or by approach-ing any member of the TK-System directly. For specialists involved in the relevant area, please look under Expert Groups (as above). If the project is not pursued we guarantee that intellectual property rights are wholly respected.

past 50 years of the AO. To this end, an interactive section has been created on the website where ev-eryone can submit their memories, anecdotes, and photographs of how the AO has touched their life.

The President of the AO Foundation, Chris van der Werken has been involved in the event plan-ning since the very beginning. He is aware of the need to strike the right balance while commem-orating the AO’s proud past. “While we will of course be reflecting on the first 50 years through-out the anniversary year, I can assure you that the AO as a whole is firmly focused on the goal of how we can continue to improve patient care. Just as it was 50 years ago.”



AO Latin America:a thriving and dynamic region

Specialty collaboration features prominently in AO activities organized on this vast continent.

AO Latin America (AOLAT)In 1998, AO Alumni Association members in Latin America formed AOLAT, an AO region. Since its inception, AOLAT’s success and influence has grown tremendously under the leadership of its presidents, Jaime Quintero (1998–2002), Fiesky Nuñez (2003–2007), and the newly elected Carlos Sancineto (2007–2009) from Argentina.

AOLAT is currently very active in all three spe-cialties across 17 different Latin American coun-tries, and over 3,000 members participated in one of 49 courses and five seminars offered in the region in 2007.

Two new countries are currently being drawn into the AOLAT fold. Puerto Rico joined in 2007 and will have its first AOLAT seminar this year.

In 2007, the first ever AO trauma seminar in Cuba was held in Havana under the direction of Fernando de la Huerta.

AOLAT’s specialty collaborationReorganization in 2006 saw Trauma and CMF join Spine in having a regional specialty board, with each board chairperson represented on the AOLAT Executive Board. There were four Execu-tive Board meetings in 2007, something which contributes to a more integrated region, both in terms of specialties and countries.

This momentum of specialty collaboration was maintained by a multispecialty event on re-search and clinical investigation that took place in 2007 in Cancún, Mexico. More than 100 doc-tors drawn from all three specialties attended,

Luis Javier ParraAOLAT Regional Director

[email protected]

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and top researchers kept the participants en-thralled by their insights. Additionally, a Tips for Trainers course was held in Panama for all three specialties.

AOLAT regional office supportIn February 2006, Luis Javier Parra began work in the AOLAT office in Colombia. Over the past two years he has supervised many exciting changes and process implementations. The complexity of the region and the interrelationships between the various bodies is evident from the diagram at left. Parra has understood and planned the changes in structure to handle this complexity while maintaining normal operations without any disturbance. He has also maintained a close collaboration with the AOSpine regional office in Brazil.

2 Passing the presidential baton: Fiesky Nuñez

welcomes Carlos Sancineto in 2007.

1 The Temple of Kukulkan at Chichen Itza, Mexico.

Visual representation of how the AOLAT region is organized.

2

AO Latin AmericaExecutive Board

AOSpine Latin AmericaRegional Board

AOSpine Latin AmericaRegional Board

AO Latin AmericaSpecialty & Country Support / Executive Office

AO CMF Latin AmericaRegional Board

AO Trauma Latin AmericaRegional Board

23community zone From the regions


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Administration also forms a large part of the work Parra’s office carries out. New agreements with the main airlines that fly into and out of Latin America have been made. Similar agree-ments with major hotel chains to host board meetings and courses should also lead to further cost reductions.

The regional office is not only responsible for local events and courses, but is also involved in supporting fellowships and Socio-Economic Committee activities.

Communication is also an essential element. This is mainly achieved through the infoLAT newsletter, sent out three times in 2007 to all Trustees and AOLAT doctors and of which four issues are planned for 2008. The AOLAT website (www.aolat.org), which kicked-off in 2006, is to be overhauled this year. It will become the main source of timely AOLAT news and information

resulting from the close collaboration of the re-gional specialty boards.

Clinical investigation in Latin AmericaAOLAT is also heavily involved in clinical re-search. For example, eight hospitals are tak-ing part in an international study sponsored by AOSpine and managed by AOCID on the assess-ment of surgical techniques for treating cervical spondylotic myelopathy. No continent provides more sites for this worldwide prospective cohort study than Latin America. Other specialties are also identifying similar projects that take advan-tage of this regional feature. A bright futureAOLAT is a region that is thriving due to the AO Foundation’s regionalization policy. Given the distances, differences in living standards, and languages involved in Latin America, it is likely to remain a very dynamic region for AO activities.

3 AO trauma group at an AOLAT multispecialty event,

Cancún, Mexico, 2007.

4 Luis Javier Parra (left) with Carlos Sancineto at the AOLAT

Jubilee Meeting in Puerto Iguazú, Argentina, 2008.

5 Participants in a multispecialty Tips for Trainers

course in Panama, 2007.

6 AOSpine participants at a 2007 AOLAT multispecialty

event in Cancún.

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AO Portal redesign Visitors to the AO Foundation website (www.aofoundation.org) since mid-March

2008 have been greeted by a completely overhauled and streamlined website that boasts a variety of enhanced features.

Background to the redesignThe AO Foundation has had an In-ternet presence since 1994. Both technology and the AO have of course made great strides since then. In 2001 it was decided to de-velop the AO website into a knowl-edge portal. Content was continu-ally added over the past few years, leading to a website comprised of approximately 12,000 active pages.

However, adding content alone was not enough to meet the needs of users, many of whom visited the AO Portal with very specific intentions in mind. There was a growing real-ization within the AO Foundation’s Web Editorial Board that the needs of users had to be addressed. With so much content on offer, finding the pages of interest was becoming increasingly more problematic for users.

Just under a year ago the redesign of the website began involving members of the AO’s Knowledge Services and Communications & Events teams. The main focus was on making it easier for users to nav-igate to the page they wanted in as few mouse clicks as possible.

The many sections of the website were identified, broken down and then rebuilt in a logical manner. Cognizance was also taken of the areas which have grown in impor-tance over recent years to ensure that they were given appropriate prominence as part of the newly designed structure.

The proposed new website configu-ration went through various test models on paper and feedback was sought from various departments and institutes internally until the current structure was arrived at.

A team of computer specialists from the AO’s Knowledge Services team was kept very busy over the past few months migrating content from the old website to the new one.

On March 13, 2008, the newly re-designed website went live and feedback received from users has been very positive. The AO Portal will continue to remain the pri-mary source for AO information for many users the world over.

See the new look website for your-self at www.aofoundation.org.

Diarmuid De FaoiteEditor, AO Communications & Events

[email protected]

What the revamped AO Portal has to offer users:

Greater overview

A logical grouping of AO activities

More modern, streamlined design

Regions and specialties more prominently featured

Expandable menus

123

54 The top 5 users, by country, were US,

then Germany, UK, Italy, and Spain.

Over 36,000 users visited the portal.

More than 1 million pages were viewed.

The average duration of a visit was, impressively, just over

10 minutes.

Selected statistics, March 2008:

The single most frequent visitor is in Germany.

25community zone Internet


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Rodrigo Pesantez

This article introduces a series of contributions concerning new techniques of minimally invasive fracture surgery.

In an editorial in “Injury” Stephan Perren asked two ques-tions:1. What can we expect from minimally invasive technology? 2. Are the length and the position of the skin incisions

critical? Although we still are looking for the answers, minimally in-vasive surgery has become part of many different surgical spe-cialties. In fracture treatment it began with intramedullary nailing and external fixation, and has evolved to become part of the orthopedic surgeon’s armamentarium with all types of implants.

Minimally invasive surgical technique avoids the additive open surgical trauma to the noninjured components of the fracture site by preserving the vascularity to the bone, perios-teum, and soft-tissue structures. During the late eighties, Jef-frey Mast, Ronald Jakob, and Reinhold Ganz published “Plan-ning and Reduction Techniques in Fracture Surgery,” which reported their techniques for indirect reduction of fractures. These methods decrease the surgical dissection at the fracture site and rely on traction across the intact soft tissues to obtain a reduction. Although compression was still widely applied for fracture stabilization, the goal of these procedures was to maintain bone perfusion so as to assure a “biological internal fixation.”

Krettek et al published their results on minimally invasive plate osteosynthesis, initially using conventional plates (DCS, angle blade plates, LC-DCP, etc) and then evolved to locked in-

ternal fixators and LCPs. Despite these “new advances,” what must be realized is that all fracture fixations must respect the viability of the soft-tissue components in the zone of injury. To achieve this goal, new reduction clamps and instruments were developed to improve the quality of reduction and ease of per-cutaneous plate application. But malalignment and in adequate fracture fixation are the price we pay if care is not taken in the application of minimally invasive fracture surgery.

In the last issue of AO Dialogue, there was an excellent review about intramedullary nailing and its expanded indications. In this issue, several experts in minimally invasive plate osteo-synthesis will outline how to apply this technique successful-ly. William Belangero, Juan Concha, and Bruno Livani review the use of plates in humeral shaft fractures, Rami Mosheiff takes a look at the different options around the pelvis and ac-etabulum, and Edgardo Ramos, Fernando Garcia, and Gabriel Chávez discuss the lower extremity.

Minimally invasive techniques for fracture treatment will continue to evolve, and probably what is today considered minimally invasive will be considered maximally invasive in a few years. So we have to keep on working to improve our current techniques for the future.

Minimally invasiveosteosynthesis

Rodrigo PesantezFundacion Santa Fe de Bogotà, Orthopedic Surgery, Bogotà, [email protected]


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27expert zone clinical topic

Minimally invasive plateosteosynthesis of the humeral shaft

William Dias Belangero, Juan Manuel Concha and Bruno Livani

The application of minimally invasive surgical techniques with humeral shaft fractures.

Although conservative management of humeral diaphyseal fractures has shown good results in about 90% of cases [1, 2], there are both absolute and relative indications for surgi-cal treatment, such as polytrauma, open fractures, bilateral fractures, floating elbow, etc [3]. Minimally invasive surgical techniques in diaphyseal fractures of long bones have shown advantages over the open conventional techniques, especially when they preserve the biological media of the fracture focus allowing a better environment for consolidation with fewer complications such as infection and nonunion [3, 4]. These techniques have not been very popular in the humeral diaph-ysis due to its anatomical complexity and the fear of damaging vital structures.

The surgical technique was described in Belangero and Livani´s publication [5]. Based on cadaveric anatomical stud-ies and clinical experience with 43 cases, the most relevant points of the surgical technique will be presented so compli-cations that may derive from faulty indications or inadequate technical performance are avoided.

Contraindications for the application of this technique As in every biological fixation method, the objective is to achieve relative stability at the fracture site so that callus is formed. Thus patients with a compromised soft-tissue environment such as a flaccid paralysis (brachial plexus lesion, poliomyeli-tis, etc) or open fractures with soft-tissue loss are contraindi-cated for this procedure [5].

Surgical technique for fractures of the middle third of the humerus

Patient positioning The patient is in the supine position, with the arm resting on the surgical table and the elbow flexed to approximately 70°. The forearm and the elbow are kept in this position by an assistant who applies slight traction during the whole procedure. This position facilitates access for plate in-troduction reducing the risk of vital structure injury.

Surgical approach An anterior approach to the surface of the humerus should be used to avoid a radial nerve lesion. Two cuts, approximately 3 cm long, are made on the anterior arm surface. The proximal access is located between the biceps brachii muscle medially, and the deltoid and the cephalic vein laterally. The distal access is located on the anterior surface of the arm and the biceps muscle is retracted medially. After the lateral cutaneous nerve of the forearm is identified, the brachii muscle is longitudinally split to expose the anterior surface of the humerus. Brachialis function is not compro-mised due to its double innervations. Under no circumstances should lever retractors be used for humeral exposure. Instead, Farabeuf type retractors should be applied in order to avoid radial nerve lesion from compression or stretching.

Implant placement In middle third fractures the plate should be introduced in a proximal to distal direction, sliding on the anterior surface of the humerus (Fig 1). The implant should not reach the coronoid fossa. After the plate is introduced, the first


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screw should be placed in the distal fragment and left relatively loose to allow the final fracture reduction. The varus deformity is corrected by arm abduction at 90° and rotational deviations are avoided by aligning the bicondylar axis on an orthogonal plane to the biceps brachii tendon. After these maneuvers the second screw is placed in the proximal fragment and the dis-tal one is tightened, securing the plate to the bone. Reduction quality is clinically and radiographically assessed before the remaining proximal and distal screws are placed (Fig 2).

In good quality bone only two screws inclined and well spaced need to be inserted into each bone segment. The utilization of wide plates should be avoided, as this may increase assembly rigidity and lead to retardation of fracture healing. For the same reason, locked plates should use only two locked screws in each fragment so that the assembly does not become exces-sively rigid [7].

Surgical technique for distal humeral fractures

Patient positioning The same position as used for medial third fractures.

Surgical approach The proximal access is the same as previ-ously described. For distal access, when there is not enough space for plate fixation on the anterior humeral surface, Koch-er’s incision is used to expose the lateral column of the hu-merus. Subperiosteal dissection of the brachioradialis and ex-tensor carpi radialis longus muscles, together with the radial nerve, exposes this surface. There is no need to identify the ra-dial nerve, unless it becomes necessary to explore it further.

Implant placement In this type of fracture the plate has to be contoured internally to adapt it to the lateral column and to the anterior surface of the humerus. It is introduced in a distal to proximal direction, sliding on the lateral column and the anterior surface of the humerus, with the assistant keeping the elbow flexed and the arm under slight traction, supported by the surgical table [5]. Screw insertion is similar to the pre-viously described technique (Fig 3).

Humeral fractures associated with radial nerve lesion The systematic and careful analysis of studies published in the last forty years concerning radial nerve injury associated with a humeral shaft fracture shows an incidence of 11.8%. The av-erage spontaneous radial nerve resolution rate is 70 to 80%. Therefore expectant management regarding the radial nerve is indicated [8–10].

The use of minimally invasive plate techniques has not been popular in humerus because of the fear of damaging the neu-rovascular structures that traverse the humerus. However, if employed according to these recommendations, the applica-tion of minimally-invasive technique is still possible in this situation.

In the proximal third of arm the radial nerve is not tethered by the intramuscular septum so fractures occurring in this region usually cause a neuropraxia, with greater possibility of spontaneous recovery. In the distal third of the humerus the radial nerve is tethered by the intramuscular septum and in close contact with the humeral diaphysis, creating a great-er chance of nerve injury by fracture site impingement thus

Fig 1 Approach and plate insertion.

Fig 2 Immediate postoperative x-rays and result 4 months postoperatively.

Fig 3 Surgical approach and plate insertion in a distal diaphyseal fracture.

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making spontaneous recovery unpredictable [10]. When the treatment of choice for distal third humeral fractures with a radial nerve lesion is the MIPO technique, the nerve should be first explored by means of an oblique access between the brachialis and brachioradialis muscles. After its identification, the nerve should be explored past the fracture site and its entry through the lateral intermuscular septum (Figs 4–6). Follow-ing that procedure, the same technique already described for distal humeral fractures is performed [6].

Conclusion Minimally invasive osteosynthesis is a simple technique, reproducible, with few risks. The method is sup-ported by the fact that the radial nerve crosses the anterior surface of the humerus only in its distal third. Thus, the iatro-genic lesion of this structure will only take place if the implant is not placed in the anterior surface of the diaphysis or if there is nerve contusion or compression as a result of inadequate use of retractors or levers during humeral exposure.

Bibliography

1. Belfour GW, Marrero CE (1995) Fracture brace for the treatment of humeral shaft fractures caused by gunshot wounds. Orthop Clin North Am; 26:55–63.

2. Latta LL, Sarmiento A, Tarr RR (1980) The rationale of functional bracing of fractures. Clin Orthop; 146:28–36

3. Green A, Reid J, Du Wayne A (2005) Fractures of the humerus. OKU: Trauma 3 American Academy of Orthopaedic Surgeons; 169–178.

4. Baumgaertel F, Buhl M, Rahn BA (1998) Fracture healing in biological plate osteosynthesis. Injury; 29 (suppl 3):C3–C6.

5. Livani B, Belangero W (2004) Bridging plate osteosynthesis of humeral shaft fractures. Injury; 35:587–595.

6. Livani B, Belangero WD, Castro de Medeiros R (2006) Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis. J Bone Joint Surg Br; 88(12):1625–1628.

7. Perren S, Claes L (2000) Biology and biomechanics in fracture management. Ruedi TP, Murphy WM (eds), AO Principles of Fracture Management. Stuttgart New York: Thieme Verlag, 17–19.

8. Sonnebeld GJ, Patka P, Van Mourik JC, et al (1987) Treatment of fractures of the shaft of the humerus accompanied by paralysis of the radial nerve. Injury; 18 (6):404–406.

9. Shah JJ, Bhatti NA (1983) Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clin Ortop Relat Res; Jan–Feb;(172):171–176.

10. Shao YC, Harwood P, Grotz MR, et al (2005) Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. JBJS Br; (87):1647–1652.

Bruno LivaniHospital das ClinicasUNICAMP, [email protected]

Juan Manuel ConchaUniversidad del CaucaPopayán, [email protected]

William Dias BelangeroHospital das ClinicasUNICAMP, [email protected]

Fig 4 Patient with radial nerve palsy after nonsurgical treatment of a distal humeral shaft fracture.

Fig 5 The approaches used to explore the radial nerve and sliding in the plate.

Fig 6 Humeral fracture fixed by minimally invasive plate osteosynthesis.

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Percutaneous fixation of pelvic andacetabular fractures

Rami Mosheiff

The application of percutaneous fixation techniques with pelvic and acetabular fractures.

Unstable pelvic-ring injuries call for anatomical reconstruc-tion and stable fixation to allow for early function. As the surrounding anatomical vicinity contains vital vulnerable structures, the percutaneous surgical approach becomes an attractive treatment option minimizing exposure, blood loss, risk of infection, and protecting vital structures. To safely apply percutaneous reduction and fixation techniques, a thor-ough understanding of the complex three-dimensional pelvic anatomy and radiology is necessary. This knowledge is more complex than that required for long bone fixation.

Indications Although percutaneous pelvic surgery is contro-versial [1], this approach has gained popularity due to the fol-lowing:

• A pelvic-ring fracture is not an intraarticular fracture re-quiring a perfect reduction so a “near anatomical” recon-struction is accepted without significantly affecting the clinical outcome.

• The percutaneous approach complements the more “open” traditional method by minimizing the open approach in certain areas where it can be safely implemented.

The percutaneous fixation of acetabular fractures has a com-pletely different approach. This is a weight-bearing joint so anatomical reconstruction is recommended and inaccuracy in reduction and/or fixation will result in a compromised out-come. In certain circumstances, it is acceptable to achieve sec-ondary congruency while avoiding the use of extensile and

unsafe exposures. Additionally, some of the screw pathways, routinely used in percutaneous pelvic surgery, can be used in acetabular fracture fixation. The learning curve achieved during pelvic surgery procedures can be utilized for more de-manding acetabular surgery.

Implementation Implementation of percutaneous pelvic and acetabular fracture surgery occurs in three stages: un-derstanding the fracture and preoperative planning; indirect reduction techniques; and percutaneous fixation.

Preoperative planning Although 3-D CT has considerably improved the understanding of fracture patterns it has not yet allowed the percutaneous placement of plates or improved reduction techniques. Currently, the control of screw orienta-tion is possible only with fluoroscopy so strict pre-operative planning is mandatory in percutaneous pelvic and acetabular surgical treatment to avoid complications. Recently, computer programs have been developed enabling the performance of virtually all steps of the real surgical procedure including de-termination of the safe zones for fixation, precise planning of screw dimensions, and pre-checking of the percutaneous op-tion as an alternative to open approach (Figs 1–4) [2–3].

Reduction A precise closed reduction is a prerequisite for percutaneous pelvic fixation and even more so for acetabular fractures. As a consequence, there are three indications for percutaneous pelvic fixation: minimally displaced pelvic or acetabular fractures, displaced fractures with a feasible closed


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Fig 1a–b A computerized preoperative planning device (SQ Pelvis software) enables complete virtual operation on the model acquired from real patient data (CT). Using 3-D viewing tools, the virtual model of a fractured acetabulum is built. Following reduction, fixation can be undertaken. The direction and length of the screws is controlled by turning the pelvis (a) or by making the bones more transparent (b).

Fig 2 Percutaneous screw insertion by means of computerized fluoroscopic navigation system enables the simultaneous use of several radiographic projections. This system has the potential to significantly reduce radiation exposure and operative time, while allowing the surgeon to achieve maximum accuracy.

Fig 3 Three-dimensional fluoroscopy allows the acquisition of CT-like images during surgery by taking about 100 fluoroscopic x-ray images at 1° intervals with a motorized isocentric C-arm. The navigation images consist of both CT and fluoroscopic x-ray images. The advantages being that complex fractures can be better visualized and that CT images, prior to and following reduction, can be taken.

Fig 4 Immediate postoperative x-ray. Closed disruption of left side of pelvic ring with vertical displacement through left sacroiliac joint. The patient was hemodynamically unstable on arrival.

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reduction, and complex fractures in which a combination of closed and open reduction is necessary. It is quite clear that the development of closed reduction techniques is pertinent for achieving a breakthrough in this field. Recently, innova-tive table–skeletal pelvic fixation frames have been devised to secure the normal side of the pelvis to the table so as to more effectively apply the reduction maneuvers to the displaced hemipelvis [4] (Figs 5–7).

Intraoperative control Intraoperative rather than postopera-tive confirmation of the reduction and fixation can save pa-tients and surgeons from uncertainty relating to the quality of reduction and implant position. The introduction of operative 3-D imaging (SireMobil IsoC-3-D, Siemens Medical Solutions, Erlangen, Germany), combines the capabilities of routine in-traoperative fluoroscopy with resultant axial cuts, 2-D and 3-D reformations. This unique imaging modality can help the surgeon assess the acetabulum and the posterior pelvic ring anatomy intraoperatively [5–6]. The persisting disadvantage of 3-D fluoroscopes is a limited image size, however newer modifications will allow superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibil-ity as well as the elimination of the need to rotate around a fixed point (isocentricity).

Fixation Conventional fluoroscopy is used most frequently in percutaneous pelvic fixation. However, it provides only a two-dimensional image and requires multiple images in dif-ferent projections to determine the correct point of entry and trajectory of the screw resulting in prolonged exposure for the patient and surgical team screw position error and the need for a proficient and available radiology technician. The intro-duction of computerized navigational systems may overcome many of the previous objections to this technique [7–8]. Sev-eral studies have already demonstrated higher precision, de-creased radiation exposure and lower revision rates with the use of navigation techniques for percutaneous screw fixation around the pelvis and acetabulum (Fig 1).

Summary The goals in the treatment of pelvic and acetabu-lar fractures are achieving anatomic reduction of articular le-sions (sacroiliac joint, acetabulum) followed by stable fixation. Only the experienced pelvic and acetabular surgeon has the surgical judgment and experience to decide if it is possible to achieve these goals with a percutaneous procedure. If the dif-ficulties entailed in integrating the new technology despite its initial cumbersomeness is accomplished then the advanced preplanning capabilities, improved accuracy of implant place-ment, significant reduction in radiation exposure, and cre-ation of a powerful educational and quality control tool will be available.

5b5a

Fig 5a–b Preoperative x-ray (a) and CT image (b).


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33expert zone

Bibliography

1. Rommens PM (2007) Is there a role for percutaneous pelvic and acetabular reconstruction? Injury; Apr;38(4):463–477.

2. Cimerman M, Kristan A (2007) Preoperative planning in pelvic and acetabular surgery: the value of advanced computerised planning modules. Injury; 38(4):442–449.

3. Attias N, Lindsey RW, Starr AJ, et al (2005) The use of a virtual three-dimensional model to evaluate the intraosseous space available for percutaneous screw fi xation of acetabular fractures. J Bone Joint Surg Br; 87(11):1520–1523.

4. Matta JM, Yerasimides JG (2007) Table–Skeletal Fixation as an adjunct to pelvic ring reduction. J Orthop Trauma; 21(9):647–656.

5. Atesok K, Finkelstein J, Khoury A, et al (2007) The use of intraoperative three-dimensional imaging (ISO-C-3D) in fi xation of intraarticular fractures. Injury; 38(10):1163–1169.

6. Atesok K, Finkelstein J, Khoury A, et al (2008) CT (ISO-C-3D) image based computer assisted navigation in trauma surgery: A preliminary report. Injury; 39:39–43.

7. Mosheiff R, Khoury A, Weil Y, et al (2004) First generation computerized fl uoroscopic navigation in percutaneous pelvic surgery. J Orthop Trauma; 18(2):106–111.

8. Stöckle U, Schaser K, König B (2007) Image guidance in pelvic and acetabular surgery – expectations, success and limitations. Injury; 38(4):450–462.

6 7a

7b

Rami MosheiffHadassah University Medical CenterJerusalem, [email protected]

Fig 6 After external fixation and arterial embolization.

Fig 7 The Starr frame assists with closed anatomical correction of the deformity. The device is based on table–skeletal pelvic fixation: securing the normal side of the pelvis to the table and maneuvering the other hemipelvis. After reduction, percutaneous sacro-illiac fixation can easily be achieved (Courtesy of Adam J. Starr, MD).

expert zone clinical topic


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MIPO in the lower extremity: a Latin American perspective

Edgardo Ramos, Fernando García and Gabriel Chávez

Examining the benefits of MIPO in the lower extremity.

Minimally invasive plate osteosynthesis (MIPO) has become a new milestone in the development of orthopedic surgery. A recent review of traditional versus MIPO techniques has not demonstrated many differences. So why do we use MIPO?

We use it because we offer a benefit to the patient in achieving an earlier and painless rehabilitation respecting the biologi-cal fracture environment, and because it is a pleasure to per-form minimally invasive surgery, the current state-of-the-art procedure. The lower extremities offer some advantages for practicing minimally invasive procedures due to bigger di-mensions and better anatomical accessibility.

Proximal femur The dynamic hip screw (DHS) by itself is a biological fixation, so it is only necessary to diminish the inci-sion to be MIPO.Key points:• Incision according to angle plate projection.• Leave the dynamic screw 2–3 mm out the cortex.• Introduce the plate inverted inside-out; turn it with a clamp

(Fig 1).• Insert the plate in the dynamic screw end, elevating the

distal plate end making rotational movements.• 4.5 mm screw placement through the same incision or per-

cutaneously (Fig 2).

Femoral and tibial diaphysis Indications for MIPO are poly-trauma patients, hospitals without technological facilities for nailing, or local soft-tissue damage at the nail entry point.

Key points: • Choose the correct plate length, plate contouring and indi-

rect reduction. • The entry path of the plate is from metaphysis to diaphysis

(Fig 3) otherwise the plate can damage soft tissues. MIPO diminishes the necessity of bone grafting.

Distal femur In this segment minimally invasive proce-dures are useful especially if there is coexisting damage (Fig 4). They help to perform a very light, quick, and patient-friendly surgery. It may be necessary to separate the proximal end plate to engage the dynamic screw into the plate barrel if a DCS is used. We use the L-shaped tibial plate for distal femoral fractures in small patients (Fig 5).

Proximal tibia MIPO for fractures of the proximal tibia is not very common because most of them have intraarticular par-ticipation and need direct and anatomical reconstruction. De-spite the use of angular stable implants sometimes it is neces-sary to add another plate. In Mexico we use nuts as “Schuhlis” to get angular stability (Fig 6).

Distal tibia This is a very challenging area so meticulous pre-operative planning is need. Surgery has to be done following articular fracture treatment principles, with gentle handling of soft tissues and a “minimax” technique (Fig 7).

Ankle Minimal ankle displacements are unacceptable and it is very difficult to perform MIPO techniques (Fig 8). A depu-


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Edgardo Ramos Hospital de Urgencias Traumatológicas, [email protected]

Fernando García Hospital de Urgencias Traumatológicas, [email protected]

Gabriel Chávez Hospital de Urgencias Traumatológicas, [email protected]

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rated surgical technique and compari-son with the healthy side are manda-tory (Fig 9).

With MIPO techniques, we have pos-sibilities to treat a broad spectrum of injuries, offering the patients quicker surgeries with fewer complications, and bloodless, painless, and shorter re-habilitation before they return to their previous activities with very good sat-isfaction rates.


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Prehospital care of equine fracture patients

Anton E Fürst and Jörg A Auer

Considering optimal prehospital care of equine fracture patients.

The initial treatment of injuries to the equine extremity great-ly affects the chances of perfect healing especially for long bone fractures [1]. Unfortunately, most fractures are exposed to substantial additional trauma during the transportation of the injured horse. Proper emergency equine transport, first aid and fracture splinting are critical to assure the best pos-sible outcome.

Rescue of severely injured horses A specially trained large animal rescue team, operating in Switzerland and Liechten-stein, specializes in the rescue of large animals involved in au-tomobile accidents or trapped in precarious situations (Fig 1). Depending on the circumstance, it may be necessary to use a rescue net and crane or a helicopter. Rescues efforts may be conducted in the upright, lateral or dorsal recumbency posi-tions. Rescuing horses must be well planned and calmly ex-ecuted under the supervision of an experienced equine veteri-nary specialist (Fig 2). Up to now no complications have been encountered during these rescue efforts. Although every res-cue operation must be performed promptly, time is of second-ary importance to the mental well-being of the horse. As flight is a horse’s only protective response, any injury preventing this activity represents mental anguish for the animal. Thus, hastily improvised rescue procedures will be inadequate and result in additional trauma. Optimal treatment includes: ini-tial wound management, infection prophylaxis, proper anal-gesia, intravenous fluid therapy, sedation and possibly anes-thesia, stabilization of the fracture and careful and safe rescue with proper transportation.

Transport of the injured horse in a supporting harness A harness which supports the horse’s entire weight and does not interfere with their respiration and balance should be used (Fig 3). It allows the horse to rest its limbs during trans-port, reducing anxiety and pain, and improves the general attitude of the patient. It is imperative that everything is checked repeatedly throughout the transport, so that prob-lems can be immediately identified and corrected promptly. Most horses alternately rest one limb after the other. After some time, horses with a properly splinted fractured limb will frequently bear some weight on it while being supported by a harness, thereby resting the healthy contralateral limb.

Fig 1 Ideal emergency vehicle: The SUV is equipped with blinking lights and all the necessary emergency equipment for rescuing horses. The trailer has an axle constructed close to the ground, which results in a ramp with a gentle slope. The roof is reinforced to allow the installation of a support harness. A winch is built into the front wall to allow a recumbent patient to be pulled into the trailer.

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37expert zone AO Vet news

For this type of transport, a person experienced in large ani-mal rescue operations should always be present in the trailer to provide optimal care for the patient. In extreme cases, a veterinarian may be required to travel with the horse. Ex-perience has shown that horses transported with a harness arrive at the hospital in much better general condition than those that are not.

If such a rescue sling is not available, the patient should be sup-ported on all sides so the animal’s body weight leans against the wall or bales of straw placed on one side of its body (Fig 4). One has to keep in mind that the horse can neither see the

Fig 2 A horse with an ulnar fracture is rescued with the help of a crane and lifted to the trailer, which could not drive to the injured horse because of the snow. After intravenous sedation, it took between 3 and 8 minutes to accomplish this rescue.

Fig 3 A fracture patient supported by a harness is ready to be transported to a specialty clinic. A splint is applied to the limb to temporarily fix the fractured limb.

Fig 4 A horse is standing in a trailer with its properly bandaged fractured limb. The left side of the trailer is filled with straw bales to build up a lateral support for the horse.

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curves ahead of it nor the red lights suddenly appearing in front of the vehicle.

Transport of recumbent horses Horses that are unable to stand are transported to the clinic in lateral recumbency, and if anesthesia is used, it must be induced and maintained by a veterinarian (Fig 5). Transportation is as rapid as pos-sible (not to exceed 90 minutes) and requires that the veteri-narian travel with the horse. The transportation may even require police escort. Equipment required for this transpor-tation includes a mechanical or electric winch, transport mat and insulated air mattress. In order to maintain control of the horse’s well-being, an indwelling intravenous catheter is placed and intravenous fluids are started. To reduce in-jury for the recumbent horse, leather boots are placed on the hooves, and hobbles are applied to all limbs. After the halter has been removed to prevent damage to the facial nerves, the head and eyes must be well protected with padded leather headgear.

The recumbent horse is pulled into the van using a slide mat. Recently, special air mattresses have been developed for the transport of recumbent horses and are used by the large ani-mal rescue units in Switzerland and Liechtenstein. Before in-flation the air mattress is placed between the horse and the transport mat, which are then pulled into the van. Once the horse is in the trailer the mattress is inflated with compressed air in about 2 minutes and assures a comfortable ride for the patient. Horses can be transported great distances without the risk of pressure necrosis or nerve damage. Often, the amount of drugs used to sedate the horse can be reduced.

An audio-video system between the van driver and the as-sistants in the trailer helps to ensure the safety of the per-sonnel accompanying the horse. For long distances, the use of a mobile anesthetic machine operated by experienced as-sistants may be necessary. This enables the administration of intravenous fluids and supplemental oxygen (approximately 2–12 l of oxygen per minute). Unloading the recumbent horse

Fig 5 A recumbent patient was pulled into the trailer and rests comfortably on an air mattress. Two assistants help with anesthesia.

Fig 6 Left: A drawing of a horse suffering from a proximal radius fracture, demonstrating the muscle induced valgus deformity. Right: The limb is properly supported with layered bandage up to the elbow and an additional lateral splint to the shoulder, effectively counteracting the deforming forces.

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39expert zone AO Vet news

is achieved by pulling the transport mat out of the van with a winch, crane or by hand. It is important to keep track of all the types, quantities and concentrations of the medications the rescue team administered to the patient and to hand this information to the treatment team at the specialist hospital.As a rule only fracture patients with open fractures and those that cannot stand up are treated immediately by means of in-ternal fixation. The vast majority are properly diagnosed and provided with state of the art fixation by means of a splint or fiberglass bandage. During this time the horse gets used to its “stiff” leg and learns to use it.

First aid treatment Skin wounds must be treated with care. After covering the wound with a water-soluble antibiotic oint-ment, the hair surrounding the wound is removed and a ster-ile dressing applied under the bandage. With open fractures, the bone must be cleaned and covered with a sterile dressing. Immediate administration of systemic antibiotics is indicated in horses with open fractures or large wounds. The notion that analgesics should not be administered to horses with fractures is unfounded. Systemic analgesics should be given as soon as the fracture is stabilized. Fractures are rarely as-sociated with severe hemorrhage. However, pain and shock lead to substantial fluid loss, which should be replaced using intravenous fluid therapy.

In most cases, judicious use of a sedative makes the examina-tion and emergency treatment of an acutely traumatized horse much easier, particularly in horses that are already stressed from competition or are in pain. Furthermore, horses do not tolerate external coaptation well, especially when the fixation extends above the carpus or tarsus. The use of a sedative may be necessary to induce acceptance of the external coaptation device.

Pain from instability is extremely stressful for the fracture patient. Effective stabilization of the fracture substantially improves the general well-being of the animal and it is bet-ter prepared for surgery. The stabilized fractured limb allows the horse to bear some weight on it for balancing during the transport. Therefore, the horse is much quieter once stabiliza-tion has been provided. There are a variety of splints that are suitable for stabilization of equine fractures. Splints applied in two planes at right angles (90 degrees) to each other must be placed in layers to the cranial, caudal, lateral or medial aspects of the padded limb and held in place with non-elastic tape. The splint should be placed such that the contractural forces caused by the limb muscles are counteracted. From the mid-radius and distal tibia proximally, the splint cannot be applied high enough, so an additional lateral splint reaching to the shoulder is incorporated into the bandage to counteract the muscular forces, which tends to induce a valgus deformity at the fracture site (Fig 6).

The equine cast, also referred to as a synthetic splint, is formed from fiberglass tape impregnated with a polyurethane resin. It is very strong and cures quickly, is easy to apply and very light. When applying the cast, the horse should stand quietly to prevent the occurrence of micro-fractures and folds in the cast, which may reduce its strength and cause pressure sores.

Bibliography

1. Fürst A (2006) Emergency treatment and transportation of equine fracture patients. Auer JA, Stick JA (eds): Equine Surgery. 3 ed. St. Louis, MO: Saunders Elsevier, 972–980.

2. Fürst A, Keller R, von Salis B (2006) Entwicklung eines verbesserten Hängegeschirrs für Pferde: Das Tier - Bergungs- und Transportnetz (TBTN). Pferdeheilkunde; 22:767–772.

Jörg A Auer Diplomate ACVS/ECVS Equine Department, Vetsuisse Faculty, University of Switzerland, [email protected]

Anton E Fürst Diplomate ECVS Equine Department, Vetsuisse Faculty, University of Switzerland, [email protected]


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