AO Dialogue 2|10The newsletter for the AO community

Education is more than just a courseFor nearly half of a century, surgeons and ORP have looked to AO as the leading provider of medical education, and to its traditional courses as the best way to avail of it. However, faced with fast-paced medical developments and mounting practice-based demands, there is a growing aware-ness at AO that offering courses is not enough.

Urs Rüetschi, Director of AO Education (AOE), puts it best: “The needs in the healthcare envi-ronment are changing, with different pressures and a constant stream of new technologies and techniques adults seem to learn differently

than in the past and their educational needs patterns have changed.”

If a surgeon has a problem today they may look for the solution in a book, on a website, or talk to colleagues. If they decide to attend a course, they would probably opt to prepare with e Learning or Internet-based resources, DVDs, or videos. To answer these demands AOE is adopting a “blended learning” approach — different learning methods assembled in a way that addresses the learner’s needs.

[ continued on page 2 ]

Education  1

SIGN   4

AOSEC  6

TK System Focus  8

AO Research Fund  12

Regional Highlights  18

Norber t Haas  24 

Table of contents

AO Education enters a new era New initiatives fulfill AO’s mission as an innovator  

of high-quality educational activities and resources

“Program development 

is a surgeon-driven 

approach,” 

states Urs Rüetschi, head of AO Education.

Fig 1

Program development–a new approachHaving taken these findings onboard, AOE realized that an entirely new approach to postgraduate training was needed. “We now take a comprehensive view, focusing on de-veloping educational programs, not only individual courses,” Doris Straub Piccirillo, Program Developer in AOE, explains. “This also includes providing all the learning ac-tivities or products that can be linked to or embedded in an entire program of study.”

To develop comprehensive programs that offer educational experiences designed to meet practice-based demands is neither quick nor easy. It takes a systematic, ongoing, and interactive approach involving a process that Mike Cunningham and Ursula Brack, newly appointed Program Developers, call “back-wards planning”—identifying the health problem and then working ‘backwards’ to devise a solution (Fig 1).

Backwards planning is a six-step process which unfolds as follows:• Identify the problems (clinical issues) or

practice gaps• Assess the targeted learners and the learn-

ing environment• Define goals and specific, measurable learn-

ing objectives• Develop and assign educational strategies

(content & methods)• Implement the process, which includes

securing the support of relevant players (regional education committees, Faculty, internal departments, etc), developing re-sources, addressing barriers, introducing and administering the program

• Evaluate the program and obtain feedback from learners to constantly optimize the program

AOE takes a “surgeon-driven approach”—surgeon-led task forces, chosen by the AO Specialties’ education commissions, work together with AOE team members to de-sign, develop, and coordinate each step. This strategy has already been translated into ac-tion: initiatives developed in the planning of Principles-level and ortho-geriatrics edu-cation will be piloted at the Davos Courses 2010. Following evaluation and adjustments,

they will then be prepared for worldwide ap-plication. AOSpine—with support from AOE Program Development—has started to create a curriculum concept that will lead to a new generation of learning activities and resources.

Connecting the Specialties for exchange of best practiceA huge advantage afforded by AOE’s position as in-house service provider is that it operates as an active interface between the four AO Specialties, thus enabling and facilitating the sharing of best practice in program develop-ment. An excellent example is the blended approach in the Faculty development program that AOE recently established for AOSpine. While it was AOSpine’s initiative, AO Educa-tion used their expertise to build a new series of eLearning modules for Faculty training. AOE then presented the concept to the other Specialties and as a result the team is now building a similar Faculty development pro-gram for AOTrauma, adjusted to their par-ticular needs.

“We constantly synergize between the AO Specialties, who can then benefit from AOE’s accumulated knowledge and expertise. Were they to rely on external consultants, they would have to start from scratch,” Urs Rüetschi points out. The head of AOTrauma’s Education Department, Clint Miner, concurs with this assessment. “The AOTrauma Faculty development project is a good example of the benefits of using a shared service provider,” he says. “We could build upon the experience of another AO Specialty, which definitely made it easier for us.”

Blended learning equals more effective learning“Faculty development across the AO Spe-cialties certainly benefits from the cross-fertilization of ideas and expertise afforded by AO Education’s coordinating role,” says Miriam Uhlmann, Program Developer for Faculty Development. However she believes that where AOE makes the biggest contribu-tion to Faculty development is in providing the latest techniques and tools and combin-ing distance learning with live events. “Now that the theoretical elements of a course are featured online beforehand, Faculty are well

prepared for live events and can instead focus on personal, interactive elements, like shar-ing feedback and participating in small group discussions.” (Fig 2).

Four new eLearning modules for AOTrauma are now in production, involving the newly formed eServices team under the leadership of Michael Redies. “We are using different methodologies, ranging from classical web based trainings to a highly motivational “se-rious game approach”,” says Pascal Schmidt head of eLearning. A “serious game” uses the principles of game playing for achieving real learning objectives. A prototype of this method, the Müller AO Classification of Frac-tures, will be launched at the Davos Courses in December 2010 (Fig 3).

Also in the works is an “interactive video” on radiation hazards that invites viewers to identify and thereby avoid future errors in the use of C-arm technology during surgery. A large number of lectures videotaped during last year’s Davos Courses can be accessed on-line by AOTrauma members for self-directed learning or as a source for Faculty when cre-ating their own lectures (Fig 4).

Add to this the upcoming release of eBooks (as part of clinical collections) and the launch of the AO’s first two iPhone applications, and it becomes clear that AOE harnesses the best of modern media to offer surgeons and ORP a wide range of educational tools and tech-niques. The development of these resources is possible because of a wide range of skill sets in the teams of Kathrin Lüssi (Publications and Faculty Support Media) and Thomas Lopatka (Video Production).

AOE is delivering all this without neglect-ing its traditional, valued role of supporting course development and delivery of Faculty support media, publishing books and jour-nals, producing DVDs and videos, as well as advancing the ever-popular Surgery Refer-ence and AO Traumaline. “Our strategic goal,” concludes Urs Rüetschi “is to enable the AO Specialties and the AO Foundation to remain world-class educators within their areas of expertise.”

Fig 2

Fig 4

Fig 3

Educational Activities

CompetenciesLearning Outcome

CompetenciesLearning Outcome

Clinical Performance

Clinical Performance

Patient  Outcomes

Patient Health Status

Postcourse eLearning

Precourse eLearning

Course

C-arm and radiation

Clickable

C-arm and radiation

23:11

AO Dialogue 2|10 AO Dialogue 2|10 Page 2 Page 3

“A well conducted orthopedic treatment, based on a sound 

understanding of the functional anatomy of the foot, and on the 

biological response of young connective tissue and bone to changes 

in direction of mechanical stimuli, can gradually reduce or almost 

eliminate deformities in most clubfeet.” (Ponseti 1996) 

KK: Clubfoot Scores with Ponseti Treatment

Weeks of Treatment

1 2 3 4 5 - tal 5 + tal

6

5

4

3

2

1

0

Scor

e CHS

CTSCMS

Surgical Implant Generation Network (SIGN)

AO Dialogue-SIGN fellow Bhaskar Raj Pant  reports from the 2010 SIGN Conference

Bhaskar Raj Pant, Southern Philippines Medical Center, Davao, 

Philippines; bhpant@gmail.com 

Creating equality of fracture care is the raison d’etre of the annual Surgical Implant Genera-tion Network (SIGN) meeting. The community comprises surgeons from around the world who share a passion to improve the lives of their patients. The 9th Annual SIGN Confer-ence took place in Richland, Washington from Sept 15–18, 2010. The meeting kicked off with a talk on the use of SIGN Nails for antegrade versus retrograde IM Nailing of femoral frac-tures. This was followed by nearly 60 presenta-tions and workshops over the next three days.

Open FracturesThe use of IM Nails versus external fixation, with emphasis on the timely use of antibiotics and role of good debridement, was addressed. The existing classification for open fractures was discussed and a new “AO Open Fractures Clas-sification” was introduced by James Kellam. The keynote address by President of the Orthopedic Trauma Association (OTA) Tim Bray, dealt with issues in the management of hip fractures.

Wound Care and Soft Tissue CoverageThe role of negative pressure wound therapy on different extremity wounds secondary to trauma, in combination with dermatotraction, was well explained with case results from Thai-land and Philippines. The innovative modifica-

tion of locally available aquarium pumps, foam and food wraps help to produce good results. Thanks to a SIGN initiative 52 participants at-tended the Soft Tissue Flap Course organized by the Institute for Global Orthopaedics & Traumatology and University of California, San Francisco prior to the conference. There they learnt different methods of early soft tis-sue coverage to minimize infections, hospital stays and financial burden to their patients.

PelvisThe classification of pelvic fractures anatomy was explained by OTA Past President David Templeman, and the role of “Sheet Binder” in emergency management was emphasized. The different management of pelvic ring injuries both with and without C-arm was analyzed.

SpineAn update on the developments in spine trau-ma was presented by Jens Chapman while surgeons from the Philippines presented on cervical facet dislocation and spine trauma care in developing countries with the help of Orthopedics Link.

PaediatricThe aim in management of pediatric femur fractures is to restore length, alignment and ro-tation by preventing osteonecrosis and physeal injury. The different techniques of manage-ment in developing countries were discussed with the experience of Ender nailing from the Philippines. Lou Zirkle demonstrated the uses of the new paediatric nail (designed by and exclusive to SIGN) which comprises a com-bination of the SIGN-Fin nail and a flexible nail. A number of presentations focused on the functional anatomy of club foot, Pirani Scor-ing, Ponseti manipulation with serial casting, tenotomy, bracing and treatment of relapse. All the participants shared their experiences dur-ing the workshop on Ponseti manipulation and casting and common errors were discussed.

Pant Bhaskar, bhpant@gmail.com

Valera Carlito Jr, info@orthodavao.com

Reyes Esperidion, info@orthodavao.com

Department of Orthopedics, Southern Philippines Medical Center,

Davao, Philippines.

Clubfoot is easily corrected when the func-tional anatomy of the foot is well understood. The completely supinated foot is abducted under the talus which is secured against rota-tion by the ankle mortise. With the applica-tion of counter pressure by the thumb against the lateral aspect of the head of the talus, the varus, inversion, and adduc tion of the hind-foot are corrected simultaneously. This is be-cause the tarsal joints are in strict mechani-cal interdependence and can not be corrected sequentially. Most clubfeet correct with about five cast applications. The first cast corrects the cavus. Subsequent casts correct the adduction and varus by progressively abducting the foot. The last cast, in combination with tenotomy, corrects the equinus. There are three phases to applying each cast: manipulation, applying padding and plaster, and moulding after the cast is applied. Different hand positions are required for each phase.

Reliable valid measurements are key to sci-ence. The Pirani Clubfoot Score is a simple scoring system which measures the amount of clubfoot deformity. The six clinical signs seen in all clubfeet, that change in severity as the foot deformity changes, are each scored 0 (normal), 0.5 (mildly abnormal) or 1 (se-verely abnormal). Scoring the foot at every visit helps indicate to the treating practitioner if deformity is correcting satisfactorily and

Ponseti Method of serial casting monitored by Pirani’s Clubfoot Score

Report by AO Dialogue-SIGN fellow Bhaskar Raj Pant and  co-researchers at the Philippines Medical Center 

when achilles tenotomy is indicated. Scores and graphs are part of the patient’s notes al-lowing the clinicians and parents to monitor the progress of treatment.

All serial Ponseti castings from the Davao Clubfoot Club at the Philippines Medical Cen-ter, where the research was undertaken, were analysed as per Pirani’s Score (Fi g 1). Among 57 patients enrolled, 54 feet were corrected. Only three clubfeet required surgical correction. There were six relapses, the cause being lack of compliance with the foot abduction brace regimen. Based on this level of initial success, we believe that surgical release is no longer nec-essary for the majority of cases of congenital clubfeet. Ponseti Serial Corrective Casting when monitored with Pirani’s Score allows adequate monitoring, meaningful comparison of results, to know when tenotomy is indicated and to reas-sure parents regarding progress.

Fig 1 CHS – Clinical Hindfoot Score; CMS – Clinical Midfoot Score; CTS – Clinical Total Score

Top:  SIGN conference organizers and attendees

Bottom:  AO Dialogue-SIGN fellow Bhaskar Raj Pant

Pre-Casting Two week old baby with bilateral clubfoot

Casting 1st casting, April 2, 2008

Post-Tenotomy 2nd casting , June 2, 2008

Brace Application of typical cast brace July 1, 2008

AO Dialogue 2|10 AO Dialogue 2|10 Page 5Page 4

AO Trustees made generous  donations to the Malawi fund during  

the June 2010 Trustees MeetingJim Harrison, reports on how these  

funds are being put to use

Jim Harrison, AOSEC Africa representative

In July 2010 I had the privilege of being invited by, the then, AO President Paul Manson to speak at the AO Trustees Meeting in Lisbon on the topic of “What should the AO reasonably do for the developing world?” As a result of living and working for a decade in Malawi, I know the answer to this question is not an easy one. Paul Demmer, recently retired Chair of the AO Socio Economic Committee (AOSEC), and I have spent hours discussing this issue. Most aid to Africa fails to make an impact or indeed makes things worse. It fosters helplessness, or worse corruption. In AOSEC we have sought to make partnerships to help Africa to help itself—a slow and steady approach.

On presenting such a challenge to the Trust-ees, and with immediate affirmation from AO Foundation founding member Thomas Ruedi and Paul Manson, the Trustees responded with a free-will donation, amounting to CHF23,873, from their own pockets.

So how will we use the money? To help Af-ricans to help themselves, naturally! So far I have hosted a meeting of the newly formed AOSEC Africa Steering Committee—a group of three doctors and one nurse leading various aspects of the development work. This gives us

a structure within which to grow our effective-ness and have an impact across the continent.

A Zimbabwean nurse, Cebelihle Ndlovu, has been sponsored to participate in our first re-gional nurse fellowship hosted at Beit Cure International hospital, Blantyre Malawi. The fellowship culminated in Cebelihle taking part as junior faculty in our local ORP course. Our hope is that she and her colleagues from Bulawayo will host the first ever ORP course in Zimbabwe next year. We are discovering that teaching is essential but only contributes to an on-going transformation when balanced with continuing supportive friendships.

Regional doctor fellowships, hosted in Pretoria, South Africa, have been established for some years now. Such has been the impact of these fellow-ships, that all our AOSEC Africa Steering Team are actually former fellows. We have now been able to start a fellowship programme in Blantyre, and last week we welcomed Deo Masatu from Tanzania to start a six month fellowship here.

The donation from the Trustees has spurred a gentle acceleration in the process of Africans teaching and encouraging fellow Africans in the face of the huge challenge of caring for our trauma patients. Thank you!

Jim Harrison, third from left, with members of the AOSEC Africa Steering Committee

New Tanzanian fellow, Deo Masatu

“I consult this book to answer questions or to complete in-formation that I need to apply in my job. It is very useful for the preparation of ORP training programs. The basic concepts are clearly explained and it gives good direction on how to standardize patient care and safety in the operating room,” according to Myriam Sanchez, ORP, Chile.

Techniques and Principles for the Operating Room by Matthew Porteous and Susanne Bäuerle 

The Techniques and Principles for the Operating Room book was con-ceived as a guide for operating room personnel (ORP). However residents embarking on an orthopedic career will also find it an excellent introduction to trauma surgery.

The book is divided into three sections. Section one covers the management of a trauma operating room. It contains units on con-duct, organization and the use, storage and sterilization of equip-ment. Section two outlines the basic principles of trauma care; written by experienced trauma surgeons it explains the ratio-nale behind various treatment options in a way that assumes little prior knowledge of the sub-ject. Section three is a guide to common trauma operations. A special feature of this section is the full-color illustrations of all instruments and implants for 38 trauma operations. Each opera-tion is outlined in an identical format covering: indications for surgery, patient and x-ray posi-tioning, anesthesia, disinfecting and draping, OR set-up, as well as a structured step-by-step guide to the procedure itself. Of special interest are the “key points” to surgeons and ORP in every chapter. It is lavishly illustrated not only with line drawings, for each step of the procedure, but also with photographs of each piece of equipment used.

“It works  like  a  bridge  between  stu-dents,  who  are  making  a  decision about  what  kind  of  specialty  they 

should  choose;  residents who are making  their  first  steps  in trauma and orthopedic surgery; ORP who are trying to achieve the best result in surgery and some experienced surgeons, who need a quick refresher on specific knowledge in special fields,” says Andrey Volna, surgeon, Russia.

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

AO Dialogue 2|10 AO Dialogue 2|10 Page 6 Page 7

Tobias Hüfner, Unfallchirurgische Klinik Medizinische 

Hochschule Hannover 

Amir Matityahu, Director of Education, San Francisco General Hospital,

Department of Orthopedic Surgery

Claas Albers, Director TK System, AO Foundation 

When discussing computer assisted surgery (CAS), most people immediately think of nav-igation—used as a nice tool for inserting can-nulated screws, yet complicated and not par-ticularly useful. However, CAS has far more to offer. It is a developing field that integrates fluoroscopy, CAT scan (CT) and computers, with remote sending to assist the surgeon in the pre-operative digital surgical planning, the intra-operative navigation of reduction, alignment of long bone fractures, minimally invasive hardware insertion, and intra-oper-ative post-fixation three dimensional (3-D) control. Current systems are more seamless and easier to use than earlier set-ups with an enhanced technological interface between the

AOFoundation TK System FocusAn overview of the most important areas of  

CAS technology development

software and the surgeon in the operating theater, thus enhancing the surgery quality.

HistoryIn recognition of the growing significance of CAS technology to its members, the AO Foundation set the scene to develop projects in this area more than a decade ago. The Aca-demic Council initiated a steering committee lead by Christian Krettek (Director of the De-partment of Trauma and Orthopedic surgery, Medizinische Hochschule Hannover, Germa-ny), and established a collaboration with the Maurice Mueller Research Center University Berne, Switzerland. These initiatives and the strategic paper “Technology Integration” co-authored by Tim Pohlemann, today’s TK Ex-ecutive Board Chairman, together with Lutz Nolte and Markus Hehli lead to the founding of the Navigation and Robotic Expert Group (NREG.) which soon became the Computer

Fig 1

Assisted Surgery Expert Group (CSEG). Since its first meeting in February 2001 this group has been an integral part of the AO TK System.

The other specialties addressed this area by appointing their own dedicated groups on CAS development: The Computer Assisted Surgery Working Group (CAWG), chaired by Alexan-der Schramm represents craniomaxillofacial interests. For spine surgery projects the Access & Navigation Expert Group (ANEG) was ac-tive from 2005-2009. Although the group has now been dissolved, their CAS projects were assigned to the remaining expert groups and its chairman Frank Kandziora represents this field of activity with his membership on the AOSpine TK.

As with all activities within the TK System, the AO Foundation’s main industrial partner Synthes Global is represented in these groups. Since 2004 the main projects are also devel-oped with BrainLAB AG (Feldkirchen, Ger-many). All projects in these groups are man-aged according to the established TK Milestone Concept, allowing the medical members the major decisions making power within the development process (project authorization, design freeze, TK approval) thereby ensuring products are developed according to clinical needs rather than market requirements.

ActivitiesComputers provide various options to make surgical procedures more effective, covering all aspects of surgery from planning to post-operative control. The following sub-sections provide an overview of the most important areas of CAS technology development.

Surgical PlanningModern surgical planning tools use digital x-rays and CTs in conjunction with implant databases to plan the fracture reduction and ideal implant selection (Fig 1). The pre-opera-

Co-author Hüfner with CSEG chairman Krettek and member Gebhard at a CSEG meeting

tive images are imported into a computer pro-gram that gives the surgeon the opportunity to mark the fracture lines and virtually reduce the fragments. The orthopedic surgeon then performs a virtual osteosynthesis planning the reduction maneuvers and choosing the correct implant. Anatomical CT based datas-ets of numerous specimens serve as 3D tem-plates for contouring implants. The surgeon can then share the surgical plan with other surgeons and operating room staff. This saves valuable time, increases surgeon and hospital efficiency, and decreases intra-operative er-

AO Dialogue 2|10 AO Dialogue 2|10 Page 8 Page 9

Fig 2 Fig 3 Fig 4

Fig 6

Fig 5

Fig 7

multiple planes and display them to the sur-geon on one screen. The operation can then be performed without additional images. This has the potential of reducing intraoperative radiation and increasing efficiency. CT imag-ing from intraoperative melding of multiple fluoroscopic views (3-D imaging) can also be imported into the navigation systems. In pa-tients with pelvis and acetabular fractures, this can be an invaluable tool. For instance, when inserting iliosacral screws (SI) into a dysmorphic sacrum, the corridor for screw insertion after reduction may be very nar-row and in an unusual trajectory. In order to avoid neurological injury to the L5 or S1 nerve roots, intraoperative CT scans can be performed, imported into the navigation sys-tem software, and the iliosacral screws placed into this corridor accurately (Fig 7). Moreover, when fluoroscopic imaging of the sacrum is obscured by bowl gas, intraoperative CT re-construction with navigation can allow the surgeon to safely place SI screws.

Interfaces Navigation is meant to provide more informa-tion in an intuitive way that may not be pro-vided by fluoroscopic imaging alone. Recently, through a collaboration between the CSEG, BrainLAB, and Synthes, the new Trauma 3.0 module was developed to enhance the inter-face between the surgeon and the navigation software. The experience and competence of the surgeons and the producers has resulted

a complex tibial plateau fracture, intraopera-tive visualization may be limited and fluros-copic images may not reflect the 3-D problem in an adequate fashion. Some studies report 20-30% intraoperative revision rate due to malreduction or implant malplacement. The introduction of 3-D C-arms has enhanced the quality of articular facture visualization (Fig 7). Although long term studies describing the outcomes after intraoperative CT scan-ning are lacking, this may translate to a sig-nificant improvement for the patient and help to reduce long term costs. The future imple-mentation of computer assisted navigation of orthopedic trauma surgery lies not only in long bone reduction, alignment, length, and insertion of implants but also in articular reduction.

rors. Only last year iPlan 3.0, a comprehensive tool for pre-operative planning became the first TK approved CAS tool for craniomaxil-lofacial procedures.

Intraoperative NavigationNavigation is an intraoperative creator of a virtual 3-D space that provides the surgeon with a reduced radiation visualization and ma-nipulation tool. The surgeon works in the vir-tual space and can reduce fracture fragments, accurately reconstruct rotation, length, and alignment, and then use navigatable tools to insert implants without the need to continually use x-rays (Fig 2–6). The preoperative surgical plan and imaging can be combined to achieve exceptionally accurate placement of implants with visualization of surgically relevant infor-mation. Specific fractures that can routinely be treated with computer assisted navigation are sacral/pelvic (Fig 2), acetabular (Fig 3), hip, and long bone fractures (Fig 4, 6). Moreover, the total leg axis in high tibial osteotomies (Fig 5) and long bone fractures (Fig 6) can be accurately planned preoperatively and assessed intraop-eratively to within 1–3°.

In all cases of computer assisted navigation osteosynthesis, an important step is the reg-istration process that fuses the patient data (ie, pelvis, spine, long bone) with the im-ages. Commonly, trauma surgery imaging is via intraoperative fluoroscopy. Two dimen-sional navigation systems import images in

in an intuitive, easy to use, and reliable ap-plication. The interface provides only relevant information needed by the surgeon to perform the operation with a simple, intuitive, stepwise progression during the surgery (Fig 5). More-over, the workflow can be individualized to suit each surgeon and operation or can by used as a generic tool. Well known Synthes instru-ments have been modified to allow a smooth interface with the navigation system (Fig 6). Therefore, the virtual visualization of almost every percutaneously jig driven implant is sup-ported by this module.

Intraoperative 3D Imaging For Articular ReductionArticular fracture reduction can be difficult to assess during an operation. For instance, in

AO Dialogue 2|10 AO Dialogue 2|10 Page 10 Page 11

The AO Research Fund (AORF)

A history from 1983–2010

The AO Research Review Commission (AORRC) was created to implement a new centralized review process for all research sup-ported by the AO Foundation. The AOVA elect-ed Mark Markel as Chairman of the AORRC effective January 1, 2011. Organizational and administrative support will be provided by Commission Manager, Anita Anthon.

When asked about the AORRC’s mission, Mark Markel declared that, “I’m excited about the future of research at the AO Foundation and the role that the AORRC will serve in the new central peer review process. I’m particularly pleased to continue the long history of the AO Research Fund (AORF) and its role in the peer review process. I would like to acknowledge Adrian Sugar’s vision, both during his tenure as Chair of the AORF and in his role assisting in the creation of the AORRC. The new cen-tral peer review process would not have been possible without the joint efforts of the AO Specialties and other vested partners in AO who helped create this vision. I would also like to thank the AOVA and other leaders in the AO Foundation for their support of this new centralized peer review process.”

Adrian Sugar, AORF Commission Chairman

At the end of 2010, The AO Re-search Fund (AORF) will cease to exist as a legal and eponymous entity. However, with some changes in person-nel, it will continue its work as the AO Re-search Review Commission (AORRC).

The AORF Commission was established in Bern on January 22, 1983 as the Forschun-gskommission der AO Stiftung (FORK). Its first chairman was Martin Allgöwer and its ten other members were Walter Bandi, Rob-ert Mathys, Peter Matter, Maurice Müller, Stephan Perren, Peter von Rechenberg, Robert Schneider, Fritz Straumann, Hans Willeneg-ger, and Hansjörg Wyss. Allgöwer handed over the chairmanship to Reinhold Ganz in 1985 and Ganz remained chairman for following twelve years, succeeded by Otmar Trentz from 1997 to 2000.

My first contact with AORF/FORK was as a successful applicant for a research grant which I received from, the then Commission Man-ager, Margrit Jaques. In 2001, I was nominated and then elected to the Commission, succeed-ing Joachim Prein. Initially the CMF and Spine groups were not represented on FORK and Professor Prein was the sole CMF commis-sion member prior to me. I attended my first meeting during Otmar Trentz’ tenure and dis-covered a chairman with the utmost integrity,

commission members with a broad range of surgical disciplines and pure scien-tists who constantly chal-lenged our assumptions.

I made the mistake, as did many other new members, of not realising how high a standard of reviewing was expected of me—nor how

vigorously I would have to defend my opin-ions. During a typical four to five hour meet-ing we discussed 40 to 50 grant applications and needed to make clear decisions. It always amused me when we were accused of favoring friends. Some of those accusers were the first to complain when their own applications or those of their friends were rejected.

Chris van der Werken took over the reins for a short while in 2004, during which time a successor to Prof Trentz was elected. I took over the chairmanship in 2005 and was im-mediately involved in a major reorganization at the instigation of the AO Board of Directors and the Academic Council. AORF boosted its Speciality representation and became more professional. We introduced larger Focus grants for experienced researchers in the clinical priority fields of the Specialties. I ac-knowledge the excellent collaboration that I had with Anita Anthon in bringing this new professionalism into play. Our budget was never enough—it never could be. Yet in the past 28 years we have provided CHF 51.116 million of funds to 976 applicants.

There has been a real camaraderie among Commission members. Every member is a working member with specific reviewing and decision making responsibilities. Con-sequently members conclude the meetings with the sense that they have really achieved something. The majority of members are from the Specialties and they always feel very close to their interests. I am sure that with their scientist colleagues, under the leadership of Mark Markel and with the support of Anita Anthon, this spirit of collaboration will con-tinue into the AORRC era.

Top: Handover on November 5th with Adrian Sugar and Mark Markel

Bottom: Attendees of the last AORF meeting in November 2010

The peer review process will be initiated by the AO Specialties, the AO Exploratory Research Board and other funding bodies of the AO Foundation who will issue individual calls for proposals as appropriate to their body. Proposals will be independently reviewed by at least two external experts and will be consolidated by a composite reviewer who will be a member of the AORRC. 

New central peer review process for the AO Foundation

The newly formed AO Research Review Commission (AORRC)  launches its operations on January 1, 2011

The AORRC is an independent group of world-class scientists, researchers and clinicians and is currently co-chaired by Adrian Sugar and Mark Markel. The AORRC will issue calls for the AO startup grants on the same basis that it did for the AORF. All research grant appli-cations will be discussed by the AORRC re-sulting in recommendations to the relevant funding body or AO Foundation research units. The funding body decides on funding based on the recommendation provided by the AORRC. The AORRC has recruited over 400 external reviewers to date to ensure that all AO research projects are assessed and evaluated by experienced reviewers who are experts in their chosen field. The AORRC anticipates at least two review processes in 2011 with dead-lines of February 15, 2011 and July 15, 2011. The review process takes approximately four months to complete. The AORRC looks forward to working with clinicians and scientists from around the world in order to support the most innovative and clinically relevant projects pos-sible for the AO and its mission.

The goals of the AORRC:

•   To ensure the highest possible quality of research suppor ted by the AO Foundation

•   To implement an independent peer review process that meets international standards of impar tialit y and exper tise 

•   To separate grant reviewing from funding decisions

•   To establish a central register  of all research projects within the AO Foundation 

Mark Markel Stephen Ferguson

Henk Jan Ten Duis

Christof MuellerIvan Martin

James Stannard

Wouter Dhert

In addition to the AORRC members seen here, newly elected members David Grainger, Manabu Ito and Emre Rifat Acaroglu will start their term in January 2011. Torsten Reichert

Steve Krikler Ingo Marzi

AO Dialogue 2|10 AO Dialogue 2|10 Page 12 Page 13

b

b

Teppo Jarvinen, Department Orthopedics, Tampere University 

Hospital, Tampere, Finland; teppo.jarvinen@uta.fi

Estrogen, locomotion and their interaction are true bones of contention. Wolff’s Law of “form follows function”, the operating principle of the loading-driven feedback system responsible for the mechanical integrity of the bones, was introduced over a century ago and has since become an axiom in skeletal biology. Estrogen, the primary female sex hormone, has been suggested to exert its influence on skeletal ho-meostasis by increasing the sensitivity of this mechanical control system. Subsequently, one of the leading pathomechanistic proposals for postmenopausal osteoporosis has been that the withdrawal of estrogen at menopause de-sensitizes bones to loading-induced stimuli [1]. However, we have previously shown that estrogen per se has little, if any, primary effect on the mechanoresponsiveness of bones [2]. In fact, using a novel approach of assessing bone strength relative to the locomotive loading to which they are subjected, we discovered that estrogen simply deposits an extra stock of bone in the female skeleton around puberty and then maintains this mineral until menopause—an apparent safety deposit for the purpose of re-production. This bone stock is then shed at menopause, when it becomes redundant from the reproductive perspective, marking the be-ginning of postmenopausal osteoporosis [3].

terization of various complex microstructural features of bones—an approach that seemed to be the trend in skeletal biology at the time (and still is). As a prologue to our actual experi-ments on the skeletal effects of estrogen, we published an editorial entitled “Revival of Bone Strength: the Bottom Line” [4], summarizing our approach to evaluating bones. Our pur-suit of more appropriate research methodology also led to the development and validation of a novel biomechanical testing protocol of rat femoral midshaft: Instead of the conventional testing in anteroposterior (AP) axis, we showed that rat femurs should be tested in mediolat-eral plane [5]. We also devised a tool for all researchers working with the biomechanics of bones to calculate the minimum sample size (study power) needed to detect a treatment effect in biomechanical traits with statistical significance [6].

After all this work validating our research set-up, we were able to prove our main hypothesis on the skeletal effects of estrogen, ie, that the loading-induced effects on bones were virtu-ally identical in both the estrogen-replete and estrogen-deplete animals [7]. Our data chal-lenges the alleged modulatory effect of estro-gen on skeletal mechanosensitivity. Contrary to the prevailing view [8], estrogen was not shown to have an independent effect on the

The objective of the present series of experi-ments was to either prove or disprove our hy-pothesis on the skeletal effects of estrogen, and accordingly, on the pathogenesis of postmeno-pausal osteoporosis. We hypothesized that if estrogen and loading were indeed coupled in the regulation of bone mass/strength, then their respective inhibitory/stimulatory effects should become distinct after their separate or combined removal.

Before we could proceed with these experi-ments, we had to justify our unconventional approach of evaluating bones as locomotive structures, rather than focusing on charac-

During the AO funding period, we addresseda couple of myths about osteoporosis:

Bone  quali t y  was  a  widely  embraced  concept  in 2005 as i t was said to of fer a solut ion to the classic paradox of os teoporosis: While  low bone densi t y (BMD) values are associated with increased relat ive r isk of f rac ture at the populat ion level, the predic-t ive value of BMD in an indiv idual pat ient remains qui te marginal . We argued that the ent ire concept is an “empty term”—similar  to  the Emperor ’s new clothes in the Hans Chris t ian Andersen children’s fair y tale [10,11].

Our proposal for the pathogenesis of postmenopausal osteoporosis  was  claimed  to  be  f lawed  based  on apparent  paradox:  Why  do  women  sustain  more fractures (have more fragile bones) than men, if we claim that they have stronger bones due to estrogen (at least relative to the locomotive-loading to which they are subjected)? Our response [12,13] highlighted that falling, not osteoporosis, is the most impor tant risk factor for elderly fractures. 

References:1. Lee K, Jessop H, Suswillo R et al (2003) En-docrinology: bone adaptation requires oestrogen receptor-alpha. Nature; 424(6947):389.

2. Järvinen TL, Kannus P, Pajamäk i I   et al (2003) Estrogen deposits extra mineral into bones of fe-male rats in puberty, but simultaneously seems to suppress the responsiveness of female skeleton to mechanical loading. Bone; 32(6):642–651.

3.  Järvinen  TL,  Kannus  P,  Sievänen  H (2003) Estrogen and bone—a reproductive and locomotive perspective. J Bone Miner Res; 18(11):1921–1931.

4.  Järvinen TL, Sievänen H,  Jokihaara  J et al (2005) Revival of bone strength: the bottom line. J Bone Miner Res; 20(5):717–720.

5. Leppänen O, Sievänen H, Jokihaara J et al (2006) Three-point bending of rat femur in the mediolateral direction: introduction and valida-tion of a novel biomechanical testing protocol. J Bone Miner Res; 21(8):1231–1237

6.  Leppänen  OV,  Sievänen  H,  Järvinen  TL  et al (2008) Biomechanical testing in experimental bone interventions—May the power be with you. J Biomech; 41(8):1623–1631. Epub 2008 May 5.

7. Pajamäki I, Sievänen H, Kannus P et al (2008) Skeletal effects of estrogen and mechanical load-ing are structurally distinct. Bone; 43(4):748–757. Epub Jun 20.

8. Seeman E (2003) Periosteal bone formation—a neglected determinant of bone strength. N Engl J Med; 349(4):320–323.

9. Leppänen OV, Sievänen H, Jokihaara J et al (2010) The effects of loading and estrogen on rat bone growth. J Appl Physiol; In Press.

10. Sievänen H, Kannus P, Järvinen TL (2007) Bone quality: an empty term. PLoS Med; 4(3):e27.

11. Järvinen TLN, Kannus P, Sievänen H (2008) Bone quality: Emperor’s new clothes. J Musculo-skelet Neuronal Interact; 8(1):2–9.

12.  Kannus  P,  Sievänen  H,  Palvanen  M  et  al (2005) Prevention of falls and consequent injuries in elderly people. Lancet; 366(9500):1885–1893.

13.  Järvinen  TL,  Sievänen  H,  Khan  KM  et  al (2008) Shifting the focus in fracture prevention from osteoporosis to falls. BMJ; 336(7636):124–126.

Teppo Jarvinen receiving the Berton Rahn research prize award from Adrian Sugar

cross-sectional geometry of bones. Instead, ac-cording to its primary reproductive function, the skeletal effects of estrogen were shown to be restricted to accrual of bone mass only (re-productive skeletal hormone) [3,7], and mostly at the biomechanically less relevant endosteal bone surface [9].

Skeletal effects of estrogenBerton Rahn Research Prize:

award winner summary

AO Dialogue 2|10 AO Dialogue 2|10 Page 14 Page 15

AO Clinical Investigation and Documentation (AOCID)

StudiesThe final report of the sacroiliac screw study has been completed. This randomized multicenter trial evaluated the precision of sacroiliac screw placement using computer-assisted navigation compared to the conventional technique. Two new studies have begun recruitment. Mid-foot Fusion Bolt (MFB) is a ran-domized controlled multicenter study to assess the effectiveness of surgical treatment with MFB in the early stage of diabetic-

neuropathic Charcot feet. Orbita3 is a prospective multicenter study to compare the accuracy of orbital reconstruction after fractures of the medial orbital wall and/or the orbital floor with preoperatively preformed versus non-preformed orbital plates.

Study Center Certification ProjectOver time, AOCID has been able to collect a substantial amount of study-related data concerning the quality of performance and cooperation of >200 participating study centers. Using the exist-ing “Reference Clinics Database” and based upon input from AO Specialties and the Regions, a decision was made to introduce a system for clinics as well as personnel directly involved in clinical studies to be certified by AOCID. Work on the concept is at an advanced stage. Presentations to the relevant internal AO bodies are ongoing and very positive feedback from sites and surgeons has been received. The first pilot certifying visits have already been made to sites in Switzerland and Singapore and a full launch is planned for 2011.

AwardsSabine Goldhahn, AOCID’s Senior Research Scientist and Japan specialist recently collected the Best Poster Prize at the Confer-ence of the International Society for Fracture Repair (ISFR) in London. Cross-cultural adaptation and validation of two knee function

scores for Japanese-speaking patients sprang from research conducted by Dr Goldhahn, R Takeuchi, N Nakamura, H Ishikawa, and T Sawaguchi.

Gerhard Konrad won the best presentation award at the annual congress of the German Society for Shoulder and Elbow Surgery. He presented the results of an AOCID multicenter study on func-tional results and complications in the use of Locking Proximal Humerus Plate (LPHP) on behalf of his co-authors P Hepp, C Voigt,

N Südkamp et al.

AO Technical Commission (AOTK)

5th European Experts´ Symposium

The Fifth European Experts’ Symposium took place in Mainz, Ger-many, on October 1–2, 2010. Chaired by Tim Pohlemann, Dank-ward Höntzsch, and Pol Rommens, 58 surgeons from 19 countries exchanged their clinical experiences in locked plating and intra-medullary nailing. Clinical issues, problem fractures, complications and limitations of the existing techniques were discussed by case presentations. The screening of clinical problems at an early stage triggers further developments. As part of the success control of the TK System this was the second of three symposia worldwide with identical programs. The results will be compared to analyze regional differences.

In proximal humerus, additional lateral tension bending/use of su-tures provides better results. The amount of screws in the plate head was discussed controversially and aside from the number, the geometric configuration and directions seems to have a major influence on secondary joint penetration. In proximal femur the surgeon should always use the longest suitable implant (regardless of plate or nail) and locking screws far away from the fracture zone will lower the risk of implant breakage. ASLS may be beneficial in reducing pain due to fracture movement and might have a benefi-cial influence in prevention of nonunions. In tibia plateau fractures a detailed analyses of fracture type and injury mechanisms is still important as also angular stable implants have to be placed in bio-mechanically optimal positions to avoid secondary displacement (‘posterio-medial buttress’). In nailing of the proximal tibia, what is the best approach is still under discussion. Poller screws might help to improve indirect reduction and avoid malalignment by nail insertion. If anatomically pre-shaped plates do not fit well, eg, small stature patients, malreduction may result when the plate shaft is brought down to the bone. Therefore anatomical variations have to be considered even when using ‘anatomically shaped’ plates. In the distal tibia, plating has become more successful with MIO technique. The low bend distal tibia plate showed promising results. Gap free reduction is still recommended. In simple fractures types, bridging plates seemed not to be sufficient for adequate healing reactions. If intramedullary nailing is used as a treatment in this anatomical region, ASLS is very promising but, nevertheless, the correct nail position remains essential (deep enough and central-central). Additional fibular plating remains controversial.

AO Education (AOE) New AO “apps” for trauma surgeonsAO Education and AOTrauma have launched an iPhone application (“app”) offering trauma surgeons on-the-go access to the Müller AO Classification of Fractures–Long Bones. “The app reflects the high-quality standard of our medical illustrations and also displays good-quality x-rays,” say the two project managers Kathrin Lüssi and Rudolf Elmer of AO Education.Version 1.0, in English, of this app is available exclusively through the Apple iTunes App Store (an iTunes account is required). It is compatible with the iPhone, iPod Touch and can be used on the iPad as well. Each main fracture is presented with a text de-scription, a line diagram, and in most cases an x-ray and/or CT scan. In addition, users will find detailed text-only information on fracture subgroups.

At the same time the first release of the “AO Surgery Reference” app will

also be available from De-cember 2010, providing access to core Surgery Reference content a sur-geon’s fingertips.

AO Surgery Reference: building on synergiesAO Education’s award-winning AO Surgery Reference has just launched its latest module, on the Foot. Under the executive editorship of Joseph Schatzker, authors Richard Buckley and Andrew Sands have covered the surgical management process for fractures of the talus, calcaneus, and midfoot. Modules on the pelvic ring and the skull base are under preparation.

This rigorous approach explains why AO Surgery Reference re-mains a favorite resource for trauma and CMF surgeons: more than 1, 500 users visit every day, calling up more than 15,000 pages, and most return on a regular basis. These numbers bode well for the reception the forthcoming AOVET modules will re-ceive when they are added in the months and years ahead.

The relationship between the Surgery Reference team and the AO Specialties is “highly synergistic”, says Tobias Hövekamp, Team Leader AO Surgery Reference. “We can hugely profit from what we did for AOCMF and AOTrauma—building on the strengths and avoiding the shortcomings—when we build modules for AOVET, and, hopefully, eventually for AOSpine.”

AO Research Institute Davos (ARI) 

Extramural FundingARI has received two major European funding grants from the European Commission (FP7) to fund the program area of Biomi-metic gels and polymers for tissue repair. Project 1—Gene Activated

Matrices for Bone and Cartilage Regeneration in Arthritis with EUR 493,000 granted over three years. Project 2—Biomimetic nano-fiber-

based nucleus pulposus regeneration for the treatment of degenerative

disc disease with EUR 532,000 granted over three years.

TK Innovation Prize 2010 awarded for the “Playground”Playground / OSkill is a technical training ground for trauma surgeons with a focus on manual surgical skills to enhance principles knowledge through practical hands-on exercises. This innovative mode of surgeon education has been running for several years and can be seen in action at many of the courses in Davos in 2010. It won the prestigious award TK Innovation Prize 2010, awarded during the 2010 Trustees Meeting in Lis-bon, Portugal.

eCM Impact FactoreCM, published by ARI, is a True Open Access electronic jour-nal with zero submission, publishing or accessing fees. Due to its rigorous, detailed and rapid review process eCM has seen its impact factor to 5.378, making it number one in Trauma research.

eCM XI and EORS2010 ConferenceseCM XI was held in Davos from June 28 to June 30, 2010. Around 150 participants, including biologists, clinicians, engineers, and material scientists attended the meeting, encouraging multidisci-plinary discussion and networking. The single sessions promoted exchange of expert knowledge in basic, translational, and clinical research in the field of traumatic and degenerative disc and carti-lage diseases. Specific topics included the development, mainte-nance and degeneration of cartilage and disc, as well as scaffolds, mechano-regulation, clinical problems, and repair. The confer-ence ended with sessions on clinical aspects and future repair approaches. eCMXI was followed by EORS2010, the 18th conference of the European Orthopaedic Research Society (EORS), organized by ARI, it was attended by more than 300 researchers and cli-nicians. EORS2010 had 100 oral and 140 poster presentations, in addition to the 17 invited keynotes lectures.

From the AO Service Units

AO Dialogue 2|10 AO Dialogue 2|10 Page 16 Page 17

The Power of Synergy—Working Together for a Stronger Tomor-row was the theme of the AONA sponsored scientific meeting organized by AONA in Phoenix, Arizona on November 11–14, 2010. This is the first time AONA has designed a meeting to bring surgeons in orthopedic trauma, craniomaxillofacial and veterinary surgery together to discuss challenges in muscu-loskeletal fracture management in an open, peer-reviewed, cross-specialty, scientific meeting. Over 200 participants at-tended this first successful meeting, showing the synergy that exists between the different specialties in the realm of basic

science. It also dem-onstrated the simi-larities in practice and in particular the complications that surgeons face across disciplines. Interactive discus-sions amongst the

specialties lead to new ideas for each group. As well as the scientific content, plenary lectures by AO Foundation Past President Paul Manson, Director of AO Trauma Education Steve Schelkun and President of AONA Jack Wilber, showed the AO spirit and the need to continue to strive to ensure that AO can deliver on its mission to improve patient care for those injured or crippled by musculoskeletal disease and injury.

Michael R Baumgaertner is now Pres-ident-Elect of AONA. Baum gaertner is Professor of Orthopaedic Surgery and Rehabilitation at Yale School of Medicine in New Haven, Conneticut and is the current Chair of the North American Musculoskeletal Trauma Education Committee. He will suc-ceed Jack Wilber at the 2011 Trustees Meeting in Berlin.

A new governance structure for AONA presented by AONA Presi-dent Jack Wilber. Introduced at the AO North American Trustee Council meeting in Lisbon in July 2010, all specialties had reviewed and tentatively accepted the structure pending final approval by the AONA Trustee Council. The new structure has significant benefits for the specialties including allowing for adaptability to unique situations; offering a transparent

and structured approach for AONA faculty to advance within the organization; collaboration with the AOF while respect-ing compliance requirements; allowing and enhancing cross specialty cooperation in North America.

Co-Management of the Geriatric Fracture Patient course report by orthopedic surgeon Joshua Patt. For the past 16 months I have been part of a team working towards the development of a geriatric fracture service at my hospital. Working with a multidisciplinary team proved challenging as each team member was outwardly enthusiastic about the project but maintained a self-protectionist stance with regard to his or her subspecialty. As I struggled to keep moving the project forward I found that the biggest obstacle to progress was rooted in the classic hospital turf wars. To move forward we needed to shift the paradigm and remove the pre-existing stigmas of my job and your job, as well as the risk aversion and self-protectionist strategies we have been historically taught to employ.Having recently re-turned from the co-manage ment of the geriatric fracture pa-tient course in Ari-zona in September, I have realized that I went about this process in the wrong order. The course co-directors Stephen Kates and Daniel Mendelson have put together an interactive meeting that teaches the participants how this process can only happen with open communication and partnership between specialties. The curriculum, with its combined expertise of surgeons, medical doctors and even an anesthesiologist, allow recognition of the challenges that all parties face to provide efficient surgical care. The concept of co-management allows for a more systematic, protocol driven care that has been proven to improve patient outcomes and more importantly patient satisfaction. My only regret is that I was unable to convince any of the internists from my institu-tion to join me at the course.

Profile of a giant in the world of AONA “Who’ll be the next Ted Hansen?” At the end of 2010, the AONA “Father of Traumatol ogy,” Sigvard “Ted” Hansen, retires from full-time practice. His innovations of aggres-sive and expeditious orthopedic care of polytrauma patients revolutionized the field. Up to his retirement Ted has served as Professor and Director at the eponymous Sigvard T Han-

Regional highlightsAO North America (AONA)

sen, Jr. Foot and Ankle Institute, University of Washington Medical School and he is listed in The Best Doctors in America publication. He performs specialized proc edures including foot and ankle reconstruction, total ankle arthroplasty for ankle arthritis and treatment of rheuma-toid feet and neuromuscular deformity. Ted Hansen received his medical degree and residency training at the University of Washington, Seattle and his career honors include the 1994 endowment of the Sig T Hansen Endowed Chair for Traumatol-ogy Research at UW; an honorary doctor of science degree from Whitman in 1997; and the 2000 dedication of Harborview’s Sigvard T Hansen Jr. Foot and Ankle Institute. However, he considers his top career honor to be the AO Foundation’s lifetime achieve ment award, the “Award for Innovation” which he received in 2006. Through the AO Foundation he has “met… fantastic people and been invited to teach and operate all over the world.”

Hansen is a true orthopedic pioneer who has revolutionized trauma care in the United States. Through these vast improve-ments in treatment, through his warmly personal and honest relationships with patients, and through remarkably innovative, skilled, and fearless surgeries, he has improved the quality of lives for countless patients for forty years and counting. (Mate-rial from the Department of Orthopaedics& Sports Medicine e-NEWS was used in the writing of this article.)

AO Dialogue 2|10 AO Dialogue 2|10 Page 18 Page 19

First research workshop for AOLATHeld in Panama on May 1, 2010, this initiative brought to-gether 10 participants, representing different Latin America countries and universities, as well as representatives from the AOTrauma Research Commission and AO Clinical Investiga-tion and Documentation. After one day of discussions, it was possible to identify regional weaknesses and strengths while defining a list of action points to be accomplished in future months. A first result is a proposal for a multicentric clinical prospective trial on trochanteric fractures evaluating predicting factors for mortality in Latin America population. This study, proposed by Prof William Belangero, will generate data for the first AOLAT regional publication as a team and enhance the culture of clinical investigation in AOLAT, while promoting quality in medical assistance.

First AOTrauma Asia Pacific Clinical Research ForumThis event took place in Kowloon Shangri-La Hotel, Hong Kong on September 16 and 17, 2010. The aim of this Forum was to  bring together research expertise in the region in order to demonstrate and showcase their research work and achievements within the Asia Pacific region. A total of 19 participants from eleven countries attended. Given the success of this event, the AOTAP Research Committee is planning to hold similar events in the future.

Open platform for Asia Pacific researchersAOSpine Research Commission member, Richard Williams is driving the AOSAP Research Committee into an open platform for Asia Pacific researchers, with the creation of an online Research Knowledge Forum and a new task force. The task force consists of current council members as well as prominent researchers from different countries within the region. The Research Knowledge Forum was established to support the collaboration of ideas and to foster discussions. The research committee met in Osaka in the middle of June 2010 to discuss the research protocol on the main pilot study: A Comparison of Surgical Outcome for Lumbar Degenerative Spon-

dylolisthesis with Neuro genic Claudication amongst countries of the

Asia-Pacific Region. Phase I of this project is un-derway and the Patient recruitment Phase of this pilot study will take place from March 2011 to March 2012. The next AOSAP Research Task-force meeting is sched-uled for June 2011.

AOTrauma Latin America (AOLAT) AO Asia Pacific (AOAP)

Joseph Schatzker and Christian Krettek had huge audiences attending their presentations.

AO Biomaterials Symposium As a national initiative undertaken by the Co-lombian AOTrauma, AOSpine and AOCMF chapters, the first AO Biomaterials Sympo-sium for Latin America took place in Bogotá on September 11, 2010.  Over 120 participants from the different specialty groups across the country gathered together to discuss general concepts and new trends in the clinical applications of biomaterials, bone substitutes and tissue engineering. Prof Mauro Alini Head of Musculoskeletal Regeneration Program, from the AO Research Institute in Davos (a worldwide authority in research of biotechnology, tissue engineering) introduced the participants, through eight separate talks, to basic concepts, current develop-ment and future trends of biotechnology, with emphasis in the concepts and treatment of critical sized bone defects (CSD).

The knee under a single approach The knee is a joint normally evaluated under different perspec-tives, depending on the specialist who manages its injuries. On July 1-3 2010, the Orthopedic Trauma Group of Ribeirao Preto Medical School, Sao Paulo University promoted a course for knee and trauma surgeons aimed at presenting current evidence on bone, cartilage and ligament injuries of the knee. A number of international guests supported this course: Joseph Schatzker, Christian Krettek, James Stannard, Alex Staubli, Phillip Loben-hofer, James Cook and Juan Concha. 533 physicians from 14 different countries attended the course which has also gener-ated content for online education and a book supported by the Brazilian Orthopedic Trauma Society. This successful experience will be repeated on July 5–7, 2012.

L4 degenerative spondylolisthesis

AO Dialogue 2|10 AO Dialogue 2|10 Page 20 Page 21

The AO Veterinary Advisory Committee established at  

the request of the AO Research and Development Committee

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

My view

James F KellamEditor-in-Chief

james.kellam@aofoundation.org

What is the best way for a surgeon to have a meaning-ful and ethical relationship with an or thopedic implant producer? From the outset the AO has at tempted to address this issue. When Maurice Müller first began to develop AO implants, he realized the need for skilled manufacturing and production facilit ies and suppor t. With  Rober t  Mathys  and  then  Fritz  Straumann,  he built a very strong industrial par tnership under the control of AO surgeons. In order to strengthen this, the AO Technical Commission was created, consisting of surgeons meeting with engineers and producers to discuss and approve implants. Members received no money and no patents from either manufacturers or  the  AO  and  developers  and  inventors  received minimal if any compensation. Developed to maximize the quality of the implant, its use and its technique, all  for  the  bet terment  of  patient  care,  today  it  has expanded into the AO Technical System (TK System). There are many dif ferent exper t surgeon groups who develop  implants  and  techniques  to  be  approved by Technical Commissions. This system allows sur-geons to be involved in implant development at the same time as maintaining a healthy relationship with manufacturers and avoiding the types of conflic ts that have recently arisen.

Impressum AO Dialogue 2|10Editor-in-Chief: James F Kellam Managing Editor: Olga Harrington Publisher: AO Foundation Design and typesetting: nougat.ch Printed by: Buchdruckerei Davos AG, Switzerland Editorial contact address: AO Foundation, Clavadelerstrasse 8, CH-7270 Davos Platz, Phone: +41(0)81 414 28 14, Fax: +41(0)81 414 22 97, E-mail: dialogue@aofoundation.orgCopyright © 2010, AO Foundation, Switzerland

The members have to fulfill the following duties:•   To take all efforts to fulfill the tasks and responsibilities 

set out above•   To actively support ARI within both the AO Foundation 

and external world•   To advance the interests of AO in Research and 

Development

The AOVAC meets once a year at the ARI headquarters Davos. The first meeting took place on February 12, 2010, where the AOVAC members toured the ARI facility and met with col-laborators for discussions on specific projects. During the tour the AOVAC members met with members of the Muscloskeletal Research program, the Implant Bioperformance program, the Biomedical Services program, the Innovations group and the PreClinical Testing program.

An in-depth look at the ARI animal experimentation project flow addressed:•   Animal studies at ARI•   Animal utilization authorization for animal 

studies conducted at ARI•   Animal utilization monitoring•   Animal rights in Switzerland•   Institutional Animal Care and Use Committee•   Performance of animal surgery at the ARI•   External, AO funded, animal experiments 

(not performed at ARI)

Standard Operative procedures:Eight standard operative procedures (SOP’s) for animal experi-mentation were reviewed by the AOVAC members approved. These SOP’s may be used in any AO Foundation funded proj-ects. Anyone interested should get in contact with the Director of Preclinical Studies at the ARI, Ludovic Boré.

Up to now no projects turned in by the AO Foundation Specialties to the Research review Committee, which is chaired by another veterinarian, Mark Markel, has been forwarded to the AOVAC for review of the animal use protocol. This will change in the near future.

The next AOVAC meeting is scheduled for Spring, 2011 in Davos.

AOVAC members in photo from left to right: W McIlwaith, A Goodship, J Auer, L Bouré (missing from the photo: T Schaer)

PositioningThe AO Veterinary Advisory Committee (AOVAC) was set up, at the request of the AO Research and Development Committee (AO R+D Committee), to evaluate and advise on: •   Live animal models applied at the  

AO Research Institute (ARI) in Davos •   Expand this evaluation to all AO funded projects 

using live animals DefinitionAOVAC is an interdisciplinary group of veterinarians with ex-pertise relevant to the use of live experimental animals in the area of research of the locomotor (or musculoskeletal) system. It acts as a sounding board for the usage of animal models at ARI and more widely for AO funded experimental studies. It has no budget to fund its own projects.

Tasks and responsibilitiesAOVAC’s tasks and responsibilities are to:•   To review and approve Standard Operative Protocols (SOPs) 

for preclinical models used at the ARI and for AO funded studies

•   To act as an Institutional Animal Care and Use Committee (IACUC): – Temporarily until the ARI has its own IACUC – For any AO funded study performed at a site that

has no IACUC•   To serve as a consulting/advisory committee for the Director 

of preclinical surgery at the ARI and any researcher receiv-ing AO funds

MembersMembers will be on the committee for three years. Joerg Auer acts as provisional chair of the committee for the first year. Initially it was proposed that after the first year the chair would be passed to another AOVAC member. After having established the AOVET R&D Commission, the Specialty Board AOVET decided that the Chair of the R&D Commission, Carl Kirker-Head should lead the AOVAC. This will consolidate the research activities with those of ARI and the live animal research of the AO Foundation. The chair of the committee will automatically become a member of the A O R+D committee. The four other AOVAC members are Wayne McIlwraith, Allen Goodship, Thomas Schaer, Ludovic Bouré.

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Strengthen AO Foundation as a single entity To foster the continuous growth of its activities, the AOF decided to decentralize responsibilities. This is an ongoing process in which the first experiences within the AO Specialties and AO Regions need to be carefully evaluated and corrective action taken as required. Certain interfaces need to be more clearly defined, ie, between the Regions, Specialties and the core AO Service Units. Furthermore, the need for a closer integration of the AO Regional Offices into the core processes has been identified. The first step to enable good governance was to adapt the AO Bylaws and Specialty Charters to clearly define the roles and responsibilities within our network. The changes also mandated the Presidential Team to hold the Foundation and its entities together.

Improved efficiency in resource allocation The recently established mid-term plan process will continue to be enhanced, focusing on common target setting through a bottom-up approach and more intensive collaboration to make optimal use of resources. The grouping together of research activ ities into exploratory research with focus fields and collaborativ e research programs, and start-up grants with the respective d elegation of decision-making to the appropriate funding bodies, should im-prove selection of relevant projects. This will have an impact on daily clinical practice. To maintain AO´s high quality standards, a common peer review standard and process becomes mandatory from January 1, 2011.

Interdisciplinary approach in research & innovationToday’s challenges in research cannot be isolated within Spe-cialties since many are related to biology. The human body doesn’t care about our organizational structure. Bone defects and appropriate substitutes are just one example of cross-specialty issues, infection is another, the use of wires and cables in trauma, spine, CMF and veterinary surgery another. Therefore it makes perfect sense to perform research across institutional boundar-ies. So, as in industry, where innovation groups are composed of experts from different disciplines, the AOF needs to find a

balance between specialization and a comprehensive approach. I want to see an increased focus on innovation overall. This implies improvement of patient care through new methods and concepts but also implementation of state-of-the-art technologies in all relevant areas of AO activities.

eLearning, curriculum building, new course formats We have to be aware that there’s strong competition out there in the marketplace. The AOF has been unique in its educational of-fering for decades now, but we cannot ignore the fact that young surgeons find alternative offers from a variety of organizations these days. In order to remain at the cutting-edge of education we must provide up-to-date services, especially in eLearning. Face-to-face courses remain an important part of what we do but we need to look at our course formats and the different types of practical exercises.

Global perspectives—new partnershipsThe world is facing a global trauma epidemic, especially in de-veloping countries and it is our objective to make a difference according to our mission. However, the AOF will not be able to achieve this alone. Therefore, the AOF has initiated a cooperation with the WHO’s Global Forum for Trauma Care. This is only a first step and we have to open ourselves to partners who were considered to be competitors until now eg, EFORT and other academic and scientific societies and institutions, and universities.

Stabilization & EvolutionIndependent from all changes, we carefully need to maintain the great, worldwide network, and safeguard AO’s good reputation.It will be decisive for the success of all these issues to encourage a culture of honest discussion and controversy with constructive solutions within our global network of colleagues and friends. I am looking forward to this fruitful exchange with the AO family respecting the successful history and tradition of the AOF and I encourage everybody to participate actively in the development of the AOF´s future.

New AO Foundation  President, Norbert Haas

identifies his strategic  priorities to guide  

the development of  the AO Foundation (AOF)  

during his term in office 

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