ao dialogue 3|07

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Table of contents

84

36

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community zone

Panorama

4 Events6 News

7 People7 Fellows opinion

8 Tribute to Martin Allgöwer

Report

11 The wisdom of the desert

14 Positioned for the future: AONA reorganizes its CME

From the regions

16 AO Asia Pacific

Internet

19 The AO Surgery Reference’s executive editors

Inside AO

21 The Specialty Academic Council General Trauma

expert zone

Case study

A case of a symphysis 22fracture with bilateral condyles: the debate

Clinical topic

Extending the indications of 26 intramedullary nailing

Proximal humeral fractures 27

Trochanteric femoral fractures 30

Clinical experience with the 32expert tibial nail

Focal point

Musculoskeletal surgeons 35should care about osteoporosis

AO Vet news

Plate/rod constructs for 36semi-rigid stabilization in the dog and cat

The next 50 years 39

James F KellamEditor-in-Chief

[email protected]

The AO spirit

There is one aspect of AO that contrib-utes to its longstanding success which is hardly ever mentioned and that is the “AO spirit”. This very special spirit stems from the origination of the first AO group, which was founded on the basis of a fraternity of likeminded in-dividuals—friends and colleagues—working toward a specific goal: better patient care. One has to know that within the Swiss tradition, the concept of a fraternity or confederation is nothing new, as are the values of liberty, equality, and loy-alty to serve a common purpose. This means that AO’s founding group’s re-lationships were strongly influenced by these and other values—trust and credibility being possibly the most im-portant for a professional network of surgeons. That the AO spirit is based not on vague assumptions, but on very specific values has permeated the whole organization and is now one of the cornerstones on which the AO Foundation has been built. But the AO spirit itself is not made of stone: It changes continually und is trongly affected by the fact that AO is a socalled “face-to-face” commu-nity where members know each other personally: individuals talk to indi-viduals, their opinions filter through and shape the AO spirit as much as it shapes them.

It’s called “dialogue”, I think. 16

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471275_Inhalt_1.indd 3471275_Inhalt_1.indd 3 22.11.2007 9:27:27 Uhr22.11.2007 9:27:27 Uhr

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from Chris van der Werken

President AO Foundation

A m

essa

geAONA Muskuloskeletal Faculty gathers for fo-rum The AO North America Musculoskeletal Fac-ulty held their 3rd Development Forum under the chairmanship of Steve Schelkun, Jorge Alonso, Mike Baugaertner, and Jack Wilber. Faculty partici-pants represented a cross section of faculty experi-ence and interests. The first day dealt with a review of AO Specialty Courses in hand and foot, the AO alumni and membership, research opportunities, faculty issues and AO career pathways. The second day included a brief introduction to the musculosk-eletal faculty training program with sessions on lec-turing, moderation, table instruction, small group discussion, and electronic support for education. The forum showed that AO North America Muscu-loskeletal Faculty continue to improve themselves and participate collaboratively worldwide and re-gionally.

Dear friends

The year 2008 is a special one for we will then

commemorate the first 50 years of the AO.

I wonder if any of the 13 founding members had

any inkling of the effect their group would have—

on their own lives, on accepted theories of fracture

care, and most especially, on the lives of countless

patients. We owe it to them and to others who fol-

lowed to celebrate their achievements in a fitting

manner.

We are planning many exciting activities through

the year and all over the globe. The opening cer-

emony will be performed at the AO Davos Courses

in December 2007 when the special jubilee logo

will be unveiled. A series of symposia will be put

on at congresses and AO-organized alumni events

and regional courses throughout the whole of

2008.

The 2008 Trustees Meeting will be held in Davos

and promises to be a big party for past and present

Trustees as well as AO employees and many other

guests—approximately 850 people!

The anniversary website can be accessed through

the main AO Foundation website: www.aofoun-

dation.org. Here you will find lots of information

throughout 2008. You can also send us your an-

ecdotes and pictures from AO-related events for a

special ‘memories’ section.

While we will of course be reflecting on the first

50 years throughout 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 pa-

tient care.

Just as it was 50 years ago.

Nonoperative course in Ghana Organized by Paul Demmer, Chairman of the AO Socio Economic Committee and W Addo of St Joseph’s Hospital, Koforidua, a nonoperative course was held in Ghana from July 4 to July 6. The course was well attended with lectures starting daily at 8:30 am lasting to midday. After lunch the course continued with practical exercises until the evening. Com-ments T Chagwiza: “The nonoperative course video made by AO in conjunction with the University of Pretoria was a great teaching help and we referred to it quite often.” Then, every morning one of the participating doctors gave a report of what he/she had learnt the previous day. There were some suggestions that a longer course would be preferable and that some topics deserve more focus, but overall the course was received with great enthusiasm.

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Successful AO at the German Congress for Orth-pedic and Trauma Surgery, Berlin Its scientific symposia and an improved lounge helped the AO Foundation to put its best foot forward at the Ger-man Congress for Orthopedic and Trauma Sur-gery, held in October at the International Con-gress Center in Berlin, Germany. The theme of the congress was aptly named “Looking forward—standing still is going backward” (Blick nach vorn - Stillstand ist Rückschritt), thus reflecting future developments. Around 7,000 people attended and approximately 250 meetings, workshops, and symposiums were held. The AO Foundation once again concentrated on nurturing and expanding its network with the AO Lounge the focal point for many surgeons. Also AO Foundation CEO Georg Strasser found it “an oasis of calm during the congress” concluding that “this year the AO was very successfully represented.”

Surgeon General’s award won by AO web-site When the 2007 “International Health & Medical Media Awards” were given out this year, the online-tool AO Surgery Reference was decorated with the prestigious “Surgeon General’s award”, which goes to the best me-dium for healthcare professionals. Nominat-ed by the US President, the Surgeon General is the head of the American public health ser-vice.Representing the more than 60 internation-al authors who worked on AO Surgery Ref-erence, Peter Trafton received the awards in Philadelphia on November 2. More than 12,000 surgeons viewed the website of AO Surgery Reference alone in the month of Oc-tober with its userbase further expanding.

New AO Surgery Reference module: proximal forearm The AO Surgery Reference is a webtool that allows surgeons to access surgical knowledge for refer-ence purposes during their clinical work. Due to the vast body of information it is being developed step-by-step and now the forarm fractures are “online” as well (according to the Müller AO Classification). The authors, Kodi Kojima (Brazil) and Steve Velkes (Is-rael), under the executive editorship of Peter Trafton (USA) have put together all the material describing the whole of the surgical management of forarm frac-tures in a clearly structured and easy to follow format (www. aosurgery.org)

Cooperation with Siemens Medical Solutions announced On August 29, 2007, the AO Foun-dation and Siemens Medical Solutions signed an agreement to make digital imaging techniques a standard part of global AO training programs for surgeons. A rapid transfer of progress in digital imaging technologies to clinical practice enables improved surgical procedures.

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Joshua C PattCompleted fellowships in musculoskeletal oncology and spine surgery at University of Washington, Seattle, WA

While each of us leaves residency with knowledge of how to do certain operations, what we all take away and have forever are the personal relation-ships with our mentors. These are the teachers who help us understand not just how, but when and why, we do what we do. Finding an engaging mentor provides a young surgeon with the op-portunity for personal and professional enrich-ment and an understanding of what it takes to become a leader in our profession.

My involvement with AOSpine began with a fellowship and has given me access to a group of estab-lished leaders in my chosen field. As a young surgeon it is easy to feel isolated, but through the AO Foun-

dation and AOSpine‘s educational op-portunities, I have been able to cultivate personal relationships with the pioneers and current leaders in both orthopedics and neurosurgery. My involvement in AOSpine has allowed me to establish these friendships and mentorships at the nascence of my career. Fe

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“Finding mentors on the road less traveled.”

Geoff Richards awarded Profes-sorship Geoff Richards is the Program Leader of bioperfor-mance of materials and devices at the AO Research Institute in Davos, Switzerland. Cardiff University in Wales, the United Kingdom, has appointed him Honorary visiting Professor in the Cardiff School of Bioscienc-es. This position is to take effect from September 1, 2007, until August 31, 2012.

Thomas Rüedi honored At the open-ing ceremony of the International Surgical Week of the ISS/SIC on Au-gust 25 in Montreal, Canada, Thomas P Rüedi, Switzerland, Yoshiki Hiki, Japan, and Donald D Trunkey, USA, received Honorary Memberships of the International Society of Surgery in recognition of their distinguished services rendered.Thomas Rüedi served the ISS for seven years (from 1993 to 1999) as Secretary General and in this position he organized four World Congresses/International Surgical Weeks.

Joshua C PattMD, MPHCarolinas Medical Center, Charlotte, [email protected]

AOSpine Fellows Forum in Banff, Alberta, 2007.From left to right Jens Chapman,

Troy Caron, Joshua Patt, and Carlo Bellabarba.

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well-documented evidence, supported by re-search results as well as teaching the operative techniques, enabled worldwide acceptance of the AO principles and today operative stabiliza-tion has become the standard treatment of frac-tures.

In 1967, Martin Allgöwer was appointed direc-tor of the Surgical Department at the University of Basel. He realized the need for specialization in surgery and established a department includ-ing all different surgical specialties collaborating to make the idea a success. The polytraumatized patient for example, was managed from the mo-ment of admission to the hospital by a team of different competent specialists with the most experienced surgeon as the team leader. Mar-

Martin Allgöwer was ambtious—not only

as a surgeon but in other endeavers

as well. In winter and while in Chur,

Switzerland, he often went skiing with

his whole team while joking that he

wouldn’t take it lightly if one of his

younger assistants would overtake him

on the slope. Still, some dared anyway

and afterwards there was always some

friendly verbal fighting about the true

reasons for his coming in second.

Illustration: Haab/AO Vet

tin Allgöwer also introduced innovative surgi-cal techniques in visceral surgery. At the same time he kept evaluating the outcome. He had the strength to admit unfavorable results and to change the techniques and guidelines for treat-ment accordingly.

Martin Allgöwer was a great teacher and fre-quently assisted his collaborators in operations. He was always ready to scrub in and to help to overcome complications. He was a respected personality and mentor for many generations of surgeons; his influence is visible worldwide. He received multiple honorary doctor titles from universities and honorary memberships in many societies.

We all realize that with his death we have lost an outstanding pio-neer who helped so many sur-geons in planning their careers. A very special era has come to an end; however, Martin Allgöwer will continue to influ-ence our daily activities. We are most grateful to have had the chance to know him as a friend, as a colleague, and as a surgeon and a teacher for the benefit of our patients. Many wonderful memories will keep him alive.

“His legacy of work will live on in the AO Principles he helped

to establish and popularize. “

—Chris van der Werken

Vintage Allgöwer: Martin celebrating his 90th

birthday at a dinnerparty in Zürich

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community zone Report

The wisdom of the desertAustralian AO ORP faculty member Nicola Kildea recounts her

teaching experience in Saudi Arabia

Preparations for my 2005 ORP experience in Ri-yadh included a three-month visa application process and preparation of my presentations for the course. I asked Susanne Bäuerle, AO Founda-tion‘s Director ORP/Nurse Education and myself, “Do I prepare the same type of presentation as I would for Australian participants?” The answer was, “Yes.” Since I would be teaching in a new environment, I also tried to learn as much as I could about the culture of Saudi Arabia.

First impressions My first impression of Saudi Arabia was of a hot, dry desert. The inhabitants dressed in black or white; most heads, and some faces, were covered. Initially, this seemed very strange because multi-colored style and dress are common in Australia, but I came to appreciate the individual style and

character of Saudi Arabian attire, including the abaya: the traditional black overgarment worn by most Saudi women. I was very fortunate, upon my arrival, to be given an abaya which I enjoyed wearing. It was extremely cool and comfortable and I did not have to think about what to wear each morning. This liberating experience gave me more time to think about other things.

My first outing was to the desert, where we had an exhilarating all-terrain vehicle (ATVs) ride through the rolling sand hills with some of Eu-rope’s most talented orthopedic surgeons. This culminated in a desert picnic at two large tents, one of which had desert air-conditioning. In the other tent we were served lamb roasted over hot coals and a pot of simmering rice: an amaz-ingly delicious and unique experience. Among

Nicola KildeaRegistered NurseAdelaide, Australia

[email protected]

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community zone Report

Other highlights of the Jeddah event were a tour of the old part of the city, an overview of its his-tory, and a faculty dinner in a restaurant on the beach.

My experiences as international AO ORP faculty member have expanded my understanding of other cultures and made me a better, more fo-cused AO educator, dedicated to the course par-ticipants. I know this will benefit our patients.

Great moment in history This course began with a preparatory meeting conducted by Piet de Boer, Director of AO Educa-tion, who led discussion of course-related issues and gave insightful educational tips. The courses began with a combined session of surgeons and ORP, this time with no partition between men and women.

It was also during the Jeddah courses that the AO Alumni chapter of the Kingdom of Saudi Ara-bia began; I felt privileged to be part of a great moment in history. The AO family has expanded again, this time to the benefit of patients in Saudi Arabia.

Historical tour The three-day ORP basic principles course in-cluded great discussions, a positive learning at-mosphere and excellent presentations during the practical session. The presentation and discus-sion room was small, creating an intimate envi-ronment in which participants felt comfortable asking questions.

1 Author and faculty member Nicola Kildea

introducing a participant to the practical exercise.

2 All the Jeddah course 2007 participants.

3 Jeddah 2007: participants with faculty.

Isabel Van Rie (2nd from left), Nicola Kildea (3rd from left), and Eija Vasama (5th from left).

4 The Rhiyadh 2005 facult (from left to

right): Guido Wahler, Karl Rabitsch, Mamoun Kremli, Theddy Slongo,

and Nicola Kildea.

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is a member of the Alliance for CME, the Global Alliance for CME and is a recent ACME Fellow-ship Award recipient. She comes to AONA from the FCG Institute, where she served as executive director. Jane will be working closely with the CMEAB to assure compliance and excellence in AONA CME activities.

All of these measures reflect an appropriate re-sponse by AONA to a changing regulatory environment in North America. The reorganization has not affected our CME content; and our primary commercial partner, Synthes, has always respected the integrity of CME and has supported us in establishing a new and logical organization for our CME activi-ties.

In addition to promoting inde-pendence of AONA and satisfy-ing ACCME and other regulatory guidelines, the restructuring now under way sets the stage for AONA to strategically position itself for in-creased CME leadership as regula-tory standards continue to evolve. Future steps would include estab-lishing processes for measuring the success of AONA‘s CME activities, ensuring that CME participants continue to gain knowledge and transfer that knowledge to their practices, and measuring how the organization‘s CME activities are

affecting patient care.

AONA has one of the finest CME organizations in the world, offering 60 high-quality, live, hands-on activities taught by hundreds of faculty experts in our four specialties for over 4,400 sur-geons and operating personnel every year. The changes we have implemented in order to com-ply with regulatory authorities and gain ACCME reaccreditation should be invisible to the course participants. Essentially, what these changes mean is that the outstanding CME that AONA and its commercial partners have supported for so many years is now being supported by a structure that addresses the challenges of a new compliance environment while also assuring the integrity of the educational process.

ence over CME staff that have faculty- and con-tent-related responsibilities. In Phase I of AIM, implemented in July 2007, AONA assumed di-rect employment of 13 CMED staff members who previously had been employed by Synthes. Phase II, to be completed in December, will relocate AONA staff from Synthes offices to a nearby inde-pendent office facility and provides for establish-ment of dedicated CME telephone and computer

systems and related infrastructure. The newly reorganized AONA CMED staff is now headed by Andrea McClimon, Director, AONA CMED. An-drea reports directly to Jack Wilber, MD, Presi-dent, AONA. With 11 years of service to AONA and Synthes, Andrea‘s experience includes serv-ing as Faculty Relations Manager, supporting the four surgeon-led AONA Education Committees, directing CME administration and compliance and managing other key AONA activities. Re-porting to her will be the five managers of AONA CME Course Development, Course Registration, and Faculty Relations Coordinator.

Also reporting to Andrea McClimon is Jane Mihelic, who assumed the role of Director of CME last June. With 25 years of CME experience, Jane

Jack WilberPresident AO North AmericaCleveland, OH, USA

[email protected]

“AONA has one of the finest CME organizations in

the world, offering 60 high-quality, live, hands-on

activities taught by hundreds of faculty experts in

our four specialties for over 4,400 surgeons and

operating personnel every year.”

15community zone Report


AO Asia Pacific

regionalization is alive AO Asia Pacific is a new organization which was born

under the regionalization concept.

All three specialties (orthopedic trauma, spine, and craniomaxillofacial) have their own govern-ing bodies. We do not have a chairman for AO Asia Pacific, but a coordination board resolves issues that are considered relevant for all three of the specialties. Coordination board chairmen representing the three specialties are: Tadashi Tanaka (Japan) for AO Trauma Asia Pacific; Thiam Chye Lim (Singapore) for AO Craniomax-illofacial Asia Pacific; and KV Menon (India) for AOSpine Asia Pacific.

Short formation processWithin a few months, AO Trauma Asia Pacific was formed by China, India, Australia, and New Zealand agreeing to join the former AO East Asia. G On Tong, the chairman of AO East Asia, was the driving force to bring those four new coun-tries into the former AO East Asia and rename it AO Trauma Asia Pacific. Currently, 13 countries are represented on the regional trauma board, which consists of an executive committee and 13 national delegates. In addition to Tadashi Tanaka as chairman, Bingfang Zeng as vice chairman, and G On Tong as past chairman, there are four functional committees: Education under Su-thorn Bavonratanavech (Thailand), Fellowship headed by Onkar Nagi (India), Clinical Research

Urs MattesAO Regional ManagerAO Asia PacificHong [email protected]

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Int.Trauma Board

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Asia PacificTrauma Board

HK delegates(3 for signature by two)

AO Asia Pacific Legal Entity

AO Asia Pacific Coordination Board (3 Specialty, Delegates & Urs Mattes)

AO Asia Pacific LimitedUrs Mattes & Employees

Asia PacificCMF Board

Asia PacificSpine Board

Administrative BoardGS. MP. UM

led by Frankie Leung (Hong Kong), and Com-munication and Publicity under Miles DeLa Rosa (Philippines). What about craniomaxillofacial? Similar to or-thopaedic trauma, the first steps were those of integration. Australia and New Zealand joined AO Craniomaxillofacial under Chairman Thiam Chye Lim in August 2007 at the AO CranioMax-illofacial faculty retreat in Kota Kinabalu. This group consists of 12 countries and we will cer-tainly see further expansion in the future.

AOSpineAOSpine has a different setup in Asia Pacific, pre-senting a nice model for bringing responsibilities directly down to the countries and using region-al bodies as a force to determine the framework. In AOSpine the countries decide what happens in terms of education, fellowship and and other issues deemed important at the country level.AO Asia Pacific consists of a heterogeneous group of countries. In order to ensure amiable relationships between and within the govern-ing bodies, it is important that each country be treated equally. This has led us to the concept of: One country/territory, one vote! Size must not be dominant. Our spirit is to have equal exchanges

Organizational chart of AO Asia Pacific.

between the countries. Thus, we can learn and prosper from one another‘s experience and ex-pertise.

There are still some burning issues from the past which must be solved within the next few years. No doubt, the AO group in Asia Pacific will mas-ter the future well. Regionalization not only al-ludes to the governance of the three boards but also adds support to our numerous auxillary ac-tivities.

TeachingThe fast-growing number of AO teaching ac-tivities requires regional support. On March 20, 2007, AO Asia Pacific obtained the Certificate of Incorporation from the Hong Kong authorities. Why Hong Kong? There is no doubt that in many ways Hong Kong is the center of Asia and almost every destination within Asia can be reached by plane in less than 5 hours. Hong Kong offers an efficient and transparent legal system originat-ing from its British heritage. Hong Kong also is the gateway to mainland China and many Hong Kong citizens are fluent in Mandarin which is used on the mainland. On July 23, 2007, after obtaining a Hong Kong employment permit,

17community zone From the regions


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I assumed my position at the new AO Asia Pacific office in Hong Kong, and I am privileged to work for such a prestigious organization.

Decision makingA key factor of regionalization is that the region and countries decide what best meets their local educational needs according to their develop-mental status (ie, equipment, supplies, type of work, etc). It does make no sense to teach high-tech applications of internal fixation if the equip-ment necessary to perform a fixation is not wide-ly available in a country. AO teaching must be adapted to the needs of the local surgeons. Only if we teach the right applications and procedures can the patient benefit. Further, AO teaching must occur within the principles and framework of the AO Foundation. In many countries, the number of course applicants exceeds the number of seats available. Thus, AO Asia Pacific has no choice but to define course entry criteria, par-ticularly for specialty courses (eg, pelvic, hand, minimal invasive, foot and ankle).

At the moment, most AO activities in Asia Pa-cific are devoted to organization and education. Although CME (Continuous Medical Education) accreditation guidelines are available only in a few in Asia Pacific countries (for example, Aus-tralia, New Zealand, and Japan), AO Asia Pacif-ic strives to have a high standard in education matching that of courses in the western world where CME accreditation is a serious issue. Our

goal is to be prepared as a CME accreditation pro-vider in Asia Pacific when the guidelines become a part of our world.

Fellowships Besides courses, seminars and symposia, fellow-ships play a key role. Fellowships offer a great opportunity to learn from experienced surgeons almost any place in the world. In cooperation with AO Education, AO Asia Pacific has intro-duced a new type of fellowship, called a “Starter Fellowship”, in which surgeons from developing countries are trained in neighboring countries in AO principles. Those surgeons will create a core group in developing countries and will be responsible for AO education back in their coun-tries. AO Asia Pacific and the AOAP website have further information on those fellowships.

Clinical studiesFracture is a rare disease. For this reason, Asia will become a key contributor to clinical stud-ies within the clinical priority projects of the AO Foundation. The clinical priority projects in or-thopedic trauma are large bone defects and os-teoporosis. Undoubtedly, the large populations, particularly of India and China, will offer oppor-tunities to perform clinical studies in this part of the world and to apply the same high standards of clinical studies as in Europe and North Ameri-ca. AOCID is similarly interested in clinical stud-ies in Asia Pacific.

AO Trauma Asia Pacific AOSpine Asia Pacific AO CMF Asia Pacific

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The recently established SAcC General Trauma took up its work in 2006. The group consists of ac-tive clinicians with outstanding reputations, representing the AO regions. Under the leadership of its Chairman, Nikolaus Renner, SAcC General Trauma is responsible for the identification and prioritiza-tion of clinical problems in the field of General Trauma. The identified clinical priorities are included in the direction-setting process for AO activities such as research, develop-ment, and education, and help to focus AO resources to constantly improve patient care.

Tobias HüttlAO FoundationGeneral Manager Academic CouncilBusiness Manager AO CMF Davos, Switzerland

[email protected]

into a working website. As collating all this information is very difficult, being involved in the earlier steps is invaluable.” CC: “We scrutinize the test website to check that the information is accurate and the illustra-tions clearly demonstrate the fracture at hand. The text must also be appropriate for non-native English speakers and agree with published work on the matter. A final element is to check that all the links work. This can be quite time-consum-ing and tedious (eg, the distal humeral module took about 60 hours of intensive executive edit-ing) but is also very necessary.”

ReviewCC: “The module is then submitted to the AO Specialty Academic Council (SAcC) for ratifica-tion. Nikolaus Renner, the chairman, and the SAcC perform an important quality assurance step, having at an earlier stage ensured that the module is consistent with AO philosophy.Members of the SAcC can then review the test website and make comments and recommen-dations if need be. Once these have been acted upon, the module is ready to be published.”PT: “The SAcC also help us focus on new areas of knowledge and identify areas where further research is required.”ER: “It is important that we remain neutral with regard to the implants that we recommend as the website is for everyone, not just those connected to the AO Foundation.”

The future of the AO Surgery ReferenceER: “This is unique: a website where everyone in the world with an internet connection can find their way through a maze of fracture treat-ments.” PT: “We need to identify who these users are and to learn what their expectations and needs are.”CC: “The AO Surgery Reference has been a run-away success. In its short existence, it has scooped eight internet awards, testimony to the skill of the entire team behind it. There are several new modules already in progress.”

Go to www.aosurgery.org to visit the AO Surgery Reference.

Want to address a potential clinical problem?

In 2007, major steps were accom-plished in defining a concept of how to facilitate the identification of clinical problems. A workflow was designed to ensure input by surgeons within the worldwide AO network and invite their valuable expertise and ideas for potential focus fields. In addition, a roadmapping process was established. Roadmapping is a widely used technique for support-ing strategy development, idea gen-eration, and priority setting. The roadmapping process to be used by the SAcC General Trauma was de-veloped by the Centre for Technol-

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The Specialty Academic Council General Trauma:

focus on constantly improving patient care

Guided by its new Specialty Academic Council (SAcC), General Trauma continually seeks to identify clinical problems and to promote innovative

concepts for improved fracture treatment.

ogy Management, from the Depart-ment of Engineering, University of Cambridge, which has an interna-tional reputation and proven track record for developing technology roadmaps across a range of wide range of disciplines. Focusing on idea generation and prioritization, roadmapping uses a graphical approach to visualize an entire strategy on one sheet of paper. The visual format cuts through com-plexity to highlight linkages, gaps, opportunities and potential problems, providing a framework to answer the questions: Where are we now? Where do we want to go? How can we get there? Other significant fea-

Here‘s how to approach the Specialty Academic Council (SAcC) General Trauma. You are a clinician in the field of general trauma and:

1. You have encountered a significant clinical problem in your daily practice, which is of high relevance and has not

been studied or solved until today, and/or

2. You have an idea for how to study or solve a clinical problem

Please, feel free to approach the Specialty Academic Council General Trauma or one of its members. Your input will be reviewed and you will receive a notification and feedback. If your input is considered highly relevant, it will be included in a SAcC interdisciplinary workshop to which you will be invited. Inputs and proposals can be submitted to: [email protected] feedback of an extensive network will provide valuable expertise for the direction-setting process and help to focus on relevant clinical problems to constantly improve patient care.

tures of roadmapping are its breadth and versatility: roadmaps can encom-pass a very broad scope of issues and long time frames while also focusing down on critical details. The SAcC roadmapping procedure includes interdisciplinary work-shops with surgeons, researchers, and other relevant participants. Core to this process is to have guid-ed constructive discussions with relevant parties using a logical se-quence of layers developed together with the surgeons. The roadmap becomes an effective way of captur-ing the results of these discussions and identifying well-defined clini-cal priorities.

2007 Members of the SAcC General Trauma

Chairperson:Nikolaus Renner, Switzerland (Chairperson)

Members:Piet de Boer, Switzerland

David Helfet, USA

Tobias Hüttl, Switzerland

Frankie Leung, China

Peter Messmer, Switzerland

Chris Moran, UK

Antonio Pace, Italy

David Stephen, USA

Rodrigo Pesantez, Colombia

Mark Vrahas, USA

21community zone Inside AO



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23expert zone Case study

Fig 1–3 Preoeprative panoramic x-ray and CT views.

Fig 4 Panoramic view 24 hours after surgery.

Fig 5 Panoramic view 5 days after surgery.

Fig 6 Displaced left condyle 2 weeks postoperatively.

Fig 7 Fixation of left joint, posteroperative view.

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and visible deformity in the preauricular region. In addition, the loss of condylar articulation with the fossa leads to the well-known shortening of the posterior vertical height with the resultant premature posterior occlusion and anterior open bite [3, 4]. Also reported, but less often referred to is the in-creased risk for long-term joint pain associated with the closed treatment of these displaced fractures [5]. This patient’s grouping of fractures, a symphysis fracture and bilateral subcondylar fracture, is a pattern with high risk of re-sulting in anterior open bite, posterior crossbite, and widened mandibular angles. The difficulty of treating this fracture pattern with closed treatment is a clear indication for opera-tive therapy of the symphysis fracture. With endoscopic as-sistance, the risk of complications from the surgical approach to the condyle is believed to be decreased [6], and because the patient was already receiving surgical intervention, the deci-sion to treat the displaced condyle surgically is fairly straight-forward, assuming the patient is well informed and in agree-ment.

The more difficult decision is whether to open a subcondylar fracture that appears to be nondisplaced or minimally dis-placed. In this situation, there may be little or no loss of pos-terior height or occlusal change. If the status of this fracture could be clearly determined to be nondisplaced, all the risks of surgery to that area could be avoided. Obviously, this can rarely be determined with certainty.

The method used in this situation to gain information regard-ing the function of the left subcondyle fracture was to ma-nipulate the patient’s mandible throughout the full range of mandibular motion to detect crepitus or obvious displacement of that fracture; a positive finding would be an indication to open the fracture. If, during the mandibular manipulations, the surgeon does not detect mobility or crepitus from the frac-ture segment, then there is support for treating that fracture closed. In this instance, the segment may have only a green-stick fracture or may have early callus formation. In either case, 1–2 weeks of a soft mechanical diet are all that is needed for stable healing in an otherwise healthy patient; this modi-fication of diet is usually self-imposed until pain and swelling from the other surgical sites have improved.

The reason for late displacement of the left condylar segment in this case probably cannot be determined with certainty. One possibility is that the fractured segment was interlocked well enough after repair of the other fractures to provide smooth mandibular movements at the end of surgery, but that later resorption of the fractured segments during healing created a mobile segment that became displaced by muscular forces.

Another possibility is that the operating surgeon did not de-tect a crepitus that should have indicated the need to open the fracture. In either case, the patient received the standard for closed treatment of a subcondylar fracture; namely, elas-tic therapy to maintain appropriate occlusion during fracture healing. Whether due to muscle splinting, patient compliance, or inadequate follow-up, it is clear that the elastic therapy was inadequate to overcome muscle pull, and the patient ultimate-ly returned to the operating room for open treatment of the left subcondylar fracture.

Bibliography

1. Villarreal PM, Monje F, Junquera LM, et al (2004) Mandibular condyle fractures: determinants of treatment and outcome. J Oral Maxillofac Surg; 62:155.

2. Ellis E, III, McFadden D, Simon P, et al (2000) Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg; 58:950.

3. Ellis E, III, Simon P, Throckmorton GS (2000) Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg; 58:260.

4. Ellis E, III, Throckmorton G (2000) Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg; 58:719.

5. Haug RH, Assael LA (2001) Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg; 59:370.

6. Miloro M (2003) Endoscopic-assisted repair of subcondylar fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 96:387.

Commentary 2James Q Swift, DDS

This case is one of the most challenging situations in the treat-ment of maxillofacial trauma: bilateral condyle fractures of the mandible with a corresponding symphysis fracture. Com-pared to unilateral or bilateral mandibular condyle fractures only, the addition of the symphysis fracture increases the dif-ficulty of treatment and alters surgical decision-making. If this patient had sustained the exact same fractures of the con-dyles only (without the symphysis fracture) and was treated with open reduction and internal fixation of the right condyle fracture and closed reduction or treatment of the left condyle fracture with occlusal guidance with arch bars and elastic in-termaxillary fixation, the opportunity for a more favorable outcome would have been dramatically increased. The trans-verse flaring at the inferior borders of the mandible increases the loss of vertical height or dimension of the mandibular ramus. It is also difficult to reposition the condylar segments to the premorbid condition in the glenoid fossa with the flaring


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A prospective standardized international multicenter study of the PHN was performed to answer the following basic ques-tions:• Is intramedullary nailing with a new angle stable titanium

nail a safe procedure in the treatment of proximal humeral fractures

• Does it provide a good outcome (Constant-Morley and DASH)?

In 11 hospitals, 151 fractures had been treated, of which 72 were extraarticular unifocal A type (2 part), 67 extraarticular bifocal B type (3 part) and 12 intraarticular C type (4 part, valgus impacted) (AO-classification) (Fig 3a–c). There were 37 male and 114 female patients, median age 66 years, ranging from 16–97 years. In total, 108 patients could be followed up for one year. The important complications noted were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), displacement of fragments (n=2), non-union (n=2), humeral head necrosis (n=3) and wound infec-tion (n=1).

The Constant-Morley score shows mean values of 75.3 on the injured side at one year postoperatively and 89.9 on the non-injured side. The mean DASH score was pre-operatively 5.9 and 9.3 at one year postoperatively. These results are similar to those with plate osteosynthesis. C-type fractures clearly have the worst prognosis.

Analyzing the complications, perforation of the articular sur-face by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related with a sub-optimal surgical technique. The nail has not been properly introduced or the length for the spiral blade was not exactly determined and its correct position was not controlled in-traoperatively (Fig 4). The development of nonunion (2/108) shows a ratio equal to or even better than what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments shows the limit of this procedure. In multifragmen-tary fracture types, one spiral blade will not be able to fix all fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach.

The study data as well as personal experience with the PHN since 2002 lead to the conclusion that proximal humeral nail-ing seems to be beneficial in A-type metaphyseal fractures, if not treated conservatively. Even in many B-type fractures it is still a good alternative with a more limited incision in com-parison to plate osteosynthesis. In C-type fractures, nailing is not advisable as a standard routine.

Retrospectively, the initial idea of finding a nail solution for almost all fracture types in the proximal humerus is not real-istic. Nevertheless, the PHN has a clear role in the repertoire of reliable implants for proximal humerus fracture fixation when minimal invasive approaches are desired and an angle-stable plate is not necessary.

Fig 3a Three part fracture of the proximal humerus with metaphyseal comminution.

Fig 3b Stabilization with PHN and spiral blade.


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Jochen BlumDirector Clinic for Orthopaedic Trauma and Hand SurgeryAcademic Teaching Hospital of the Johannes Gutenberg University Mainz, Worms, [email protected]

The spiral blade cannot be considered as the one and only angle-stable fixation mode proximally. Further development should focus on the integration of additional hardware at the nail’s base in order to offer a wider variety of fixation possibili-ties for more complex fracture types.

Fig 3c Fracture healing after 4 month. Correct placement of spiral blade and end cap.

Fig 4 Suboptimal surgical technique. Perforation of the spiral blade and loosening of the proximal interlocking screw (left). Protrusion of the nail base with end cap and of the spiral blade (right).

Data of the AO-multicenter-study on the proximal humeral nail (PHN) presented at the Orthopaedic Trauma Association OTA Annual Meeting in Boston (USA) October 2007 and German Congress of Orthopaedics and Trauma Surgery Berlin (Germany) October 2007.

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Trochanteric femoral nail

Michael J Gardner and Dean G Lorich

Unstable intertrochanteric fractures:lessons learned from a clinical study of thetrochanteric femoral nail.

Introduction Unstable intertrochanteric hip fractures can be difficult surgical challenges. Screw and side plate devices reliably stabilize stable fracture patterns [1,2], but unstable fractures require a mechanically optimized device and better implant purchase in the femoral head. These fractures have been more prone to implant failure with standard devices [3, 4]. The trochanteric femoral nail (TFN) is a helical blade de-vice which has fins that compact the cancellous bone as it is inserted into bone and may provide improved fracture sta-bilization characteristics [5, 6]. A retrospective study of 273 patients with intertrochanteric hip fractures who were treated with a TFN was conducted at two institutions between 2001 and 2005. Patients underwent closed fracture reduction using traction and manipulation techniques. When the reduction was unacceptable as determined by the surgeon, adjunctive percutaneous reduction techniques were utilized. Implants were placed percutaneously, and compression of the fracture was performed in the majority of fractures. Precise measure-ment of movement of the blade within the femoral head and the nail was performed on all radiographs according to a pre-viously described technique (Fig 1) [6]. The amount of tele-scoping was then measured as the lateral prominence of the blade lateral to the edge of the nail. X-ray measurements were made immediately postoperatively, at six weeks postopera-tively, and at subsequent follow-up.

Notable findings• The average blade tip migration was 2 mm. In a multivari-

ate regression, fracture stability, calcar reduction achieved, age, and gender showed no correlation to blade migration. This implies that the strong purchase of the blade in the cancellous bone of the femoral head may be able to over-come imperfect reductions of the posteromedial cortex and provides adequate stability in elderly patients.

Fig 1 A coordinate system, based on the center of the femoral head, was used to calculate the change in position of the implant over time. Measurements were corrected for rotation and magnification.

• The length of the nail was also not related to blade tip mi-gration.

• Increased telescoping in unstable fractures was controlled and limited, maintaining abductor tendon length, but did not predict subsequent cut out or additional blade migra-tion in the femoral head. Less telescoping also occurred with a greater initial lateral blade prominence (as a result of initial fracture impaction).

• After the six-week follow-up, minimal additional blade mi-gration and telescoping occurred, indicating these move-ments resulted in fracture settling in a stable position.

• Blade penetration through the subchondral bone occurred in some unstable fracture patterns and could be attributed to technical error, including varus neck-shaft angle, supe-rior blade placement in the femoral head, or distraction at the fracture site.


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A noncompliant owner/animal will markedly increase the in-cidence of implant-related complications. Catastrophic or fa-tigue plate failure are examples of implant failure associated with overuse prior to adequate bone healing (Fig 1).

Rapid callus formation Strategies to reduce the incidence of implant failure include methods to accelerate callus formation and/or methods to reduce implant stress. Methods to hasten callus formation include preservation of the surrounding soft tissue envelop during surgery and insertion of graft material to enhance osteogenesis and osteoinduction. Allogeneic and autogeneic cancellous bone grafts are frequently used in Vet-erinary surgery to stimulate osteogenesis and/or osteoinduc-tion. Preserving the soft tissue envelope, ie, atraumatic sur-gery, has always been advocated as a principle vital to the AO technique. Atraumatic technique is fundamental when man-aging comminuted fractures using indirect reduction tech-

niques. Veterinary surgeons have long adopted the principle of OBDNT. This acronym (Open But Do Not Touch) signifies an open exposure without manipulation of fragments within the zone of bony comminution. Doing so helps preserve the biologic potential of the fracture milieu and maintains an en-vironment of low interfragmentary strain. Both factors are conducive to rapid callus formation and early bone union.

Minimally invasive plate osteosynthesis Within the last de-cade, the concept in minimally invasive plate osteosynthesis (MIPO) was introduced and is becoming the standard method by which human and veterinary surgeons may achieve maxi-mal preservation of soft tissues adjacent to the fracture site. Using minimally invasive technique, soft tissue portals are made at strategic locations to facilitate bone plate and screw insertion. Spatial alignment of the fracture is achieved with the aid of intraoperative imaging; alternatively, the surgeon

Fig 1 Bone plate failure following stabilization of a comminuted tibial fracture in a dog.

Fig 2 Surgical view showing location of portals for minimally invasive plate osteosynthesis.

Fig 3 Postoperative view showing position of bridging plate and intramedullary pin for application of plate/rod construct.

Fig 4 Image showing good weight bearing 24 hours postoperatively after MIPO with a stable plate/rod construct.

Fig 5 Bone union 9 weeks postoperatively.

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