AOTK System. Innovations 2015

Transcription

1 AOTK System Innovtions 2015

2 AOTK System Innovtions is compiled y the AOTK tem. Production y AO Eduction Institute. Typeset y Nougt. DUE TO VARYING COUNTRIES LEGAL AND REGULATORY APPROVAL REQUIREMENTS PLEASE CONSULT THE APPROPRIATE LOCAL PRODUCT LABELING FOR APPROVED INTENDED USE OF THE PRODUCTS DESCRIBED IN THIS BROCHURE. ALL DEVICES IN THIS BROCHURE ARE AOTK APPROVED. FOR LOGISTICAL REASONS, THESE DEVICES MAY NOT BE AVAILABLE IN ALL COUNTRIES WORLDWIDE AT THE DATE OF PUBLICATION.

3 TABLE OF CONTENTS 1 TABLE OF CONTENTS EDITORIAL 2 IM NAILING 4 TFN-ADVANCED Proximl Femorl Niling System (TFNA) TRAUMA, UPPER EXTREMITY 11 PHILOS Augmenttion post lunch product review TRAUMA, LOWER EXTREMITY 16 VA LCP Midfoot/Hindfoot System CRANIOMAXILLOFACIAL 19 MtrixWAVE MMF NEURO 22 MtrixNEURO Preformed Mesh SYNTHECEL Dur Repir POWER TOOLS 25 EG1 Electric High Speed Drill System SPINE 26 Fcet Wedge Spine System Minimlly Invsive 2D Nvigtion-Assisted Spine Surgery in Est Afric Syncge Evolution VETERINARY 40 Doule/Triple Pelvic Osteotomy (DPO/TPO) Plte AOTK MEET THE EXPERTS 44 NEWS FROM ARI 47 Biomechnicl Evlution of Femorl Neck Frcture Fixtion with the new Femorl Neck System AO Frcture Monitor NEWS FROM AO EDUCATION INSTITUTE 51 AOTrum STRT New AO Pulictions NEWS FROM AOCID 54 Clinicl trils updte NEWS FROM AOTK 57 AOTK Experts Symposi AOTK AWARDS 59 PORTRAIT: KARL STOFFEL 60

4 2 EDITORIAL EDITORIAL Der reder, The AOTK System is plesed to nnounce the long wited return of the AOTK System Innovtions mgzine. The re-irth of this AO institution mrks new eginning nd fresh outlook on product innovtion cross our clinicl divisions of Trum, Spine, CMF, nd Veterinry. Since our lst puliction in 2013, AOTK hs witnessed two new dditions to the tem in Trum nd CMF, new Chirmn of AOSpine TK, nd renewed greement for continued collortion with our industril prtner. The focus of the AOTK, however, remins the sme; the doption of n innovtive pproch to the development of surgicl products nd techniques. This issue contins contriutions from the AO Reserch Institute nd AO Clinicl Investigtion nd Documenttion, s well s specil introduction from the AO Eduction Institute to AOSTRT, n wrd-winning online lerning hu for orthopedic trum residents. In our led rticle we introduce the Trochnteric Fixtion Nil Advnced or TFNA. This new solution from the Intrmedullry Niling Expert Group incorportes ll of the enefits of the existing TFN with dditionl improvements to specific spects of the nil design. The outcome is n innovtive implnt with promising results. The Foot nd Ankle Expert Group introduce the Vrile Angle LCP Midfoot/Hindfoot system. This system demonstrtes n extension of the significnt innovtion chieved y this group in 2013 when the VA LCP Forefoot/Midfoot system ws wrded the TK Innovtion Prize nd ecme highly successful following its introduction to the mrket. We report on the sme high level innovtion from our Spine nd CMF divisions with the introduction of Fcet Wedge nd MtrixWAVE. Both of these innovtions demonstrte continued dvncement in surgicl thought nd prctice through the development nd improvement of existing systems nd techniques. AOTK SYSTEM INNOVATIONS 2015

5 EDITORIAL 3 Following their first product demonstrtion t the Meet the Experts sessions t AO Dvos Courses 2014, the memers of AOVET hve provided more in-depth nlysis of the Doule/Triple Pelvic Osteotomy Plte. This rticle detils two exciting corrective procedures with gret clinicl results. Our portrit piece in this yer s issue fetures Dr Krl Stoffel from the Kntonsspitl Bsellnd in Switzerlnd. With the help of Dr Christoph Sommer, Chirmn of the Lower Extremity Expert Group nd Chief Trum Surgeon t Kntonsspitl Gräuunden, we hve een le to produce cndid nd insightful rticle tht certinly supports the AOTK System s decision to feture Dr Stoffel s outstnding contriution to orthopedic nd trum surgery. As referenced t the strt of this Editoril, AOTK is proud to introduce Dr Mrten Spruit s the newly ppointed Chirmn for AOSpine TK. Hving joined in 2008 s memer of the Fusion Expert Group, Dr Spruit hs demonstrted his vlue through memership nd chirmnship of the Cervicl Expert Group since We wish him the est of success in his new position nd offer our thnks to his predecessor, Dr Roert McGuire, for his knowledge, expertise, nd dediction to AOSpine TK nd the entire AO community since Roert McGuire hppily psses the reigns of the AOSpine TK Chirmnship to new Chirmn Mrten Spruit. With ll of this nd more, the 2015 edition of AOTK System Innovtions promises to e n exciting issue. We hope you enjoy it. Finlly, we would like to reiterte tht none of the rticles in this mgzine sustitute for AO s surgicl techniques nd teching tools. You cn otin more informtion out AOTK on the AO Foundtion wesite. Plese do not hesitte to contct the AOTK t ny time s we welcome your feedck nd involvement. Yours fithfully Tim Pohlemnn AOTK (Trum) Dniel Buchinder AOTK (CMF) Mrten Spruit AOSpine TK

6 4 IM NAILING Michel Bluth, Christopher Finkemeier TFN-ADVANCED PROXIMAL FEMORAL NAILING SYSTEM (TFNA) Although PFNA nd TFN niling systems hve een successfully used in the pst, severl clinicl issues for improvement hve een identified y surgeons nd engineers. Mny of these issues hve now een ddressed nd solved y implnt nd instrument design chnges incorported into the new TFNA niling system. The complictions of penetrtion or nterior corticl impingement while using long intrmedullry nils for pertrochnteric femur frctures re due to mismtch of the femorl ntecurvtion with the rdius of curvture (ROC) of currently ville cephlomedullry nils. Bzylewicz et l [1] reported tht most of the intrmedullry nils with ROC of 1800 mm ended up in the nterior hlf of the spce ville for the nil with 16% within 3 mm of the nterior cortex. Ptients tht re shorter nd/or hve n incresed femorl ow s mesured on lterl x-ry re more likely to hve n nterior nil tip position or corticl impingement [2]. To thoroughly investigte this issue, comprehensive 3D computer grphicl ntomy study of the femur ws conducted to serve s sis for new nil design [3]. Anlyzing 27 Cucsin nd 13 Jpnese sujects, the ROC resulted in 962±157 mm (Cucsin sujects) nd 790±151 mm (Jpnese sujects). These results indicte significnt differences etween ethnicities nd tht the ROC should e closer to these vlues insted of 1500 mm, which is frequently chosen rdius in current nil systems on the mrket. The new TFNA hs rdius of curvture of 1000 mm to improve the ntomicl fit nd to help void impingement of the nterior cortex (Fig 1). Fig 1 The TFNA nil, illustrted in green, hs 1000 mm ROC nd perfectly follows the ntecurvtion of most femurs. The lue nil demonstrtes less fvorle fit of simulted nil with 1500 mm ROC. AOTK SYSTEM INNOVATIONS 2015

7 IM NAILING 5 Loss of closed reduction during nil insertion Surgeons often report some loss of reduction during nil insertion, specificlly in cses involving nil insertion through frctured greter trochnter. This often leds to n unintended vristion of the hed-neck frgment (HNF) nd medilistion of the HNF resulting in reduced one contct in the clcr re (Fig 2 nd 3). c Fig 2 c A 60-yer-old femle ptient with 31-A2 frcture (). Closed reduction on the trction tle nd insertion of the guide wire (). With nil insertion, the HNF displces to medil nd vrus (c). c d Fig 3 d An 81-yer-old mle ptient. Closed reduction nd insertion of 10 mm dimeter nil (). With dvncement of the most proximl prt of the PFNA, the HNF displces to medil. This cnnot e prevented y pushing the shft from lterl with ll spike pusher (). The ttempt to reduce the clcr with colliner clmp results in pronounced vrus mllignment (c nd d).

8 6 IM NAILING The comintion of lrge proximl nil dimeter nd very lterl entry point hs een identified s potentil reson for such loss of reduction. As result, smller dimeter nil with lterlly flttened profile to more ppropritely respect the ntomy of the proximl lterl femorl wll would e dvntgeous. Both design fetures hve een relized with the new nil. The smller mm proximl nil dimeter of the TFNA (compred to 16.5 mm nd 17 mm for PFNA/ PFNA-II nd TFN) nd the LATERAL RELIEF CUT design (Fig 4) of the proximl nil end serve to reduce the potentil impingement of the nil with the lterl femorl wll nd the HNF. Both of these issues could result in vrus mllignment nd loss of reduction, which remin key indictors for n incresed risk of cut-out. The smll proximl nil dimeter lso helps to preserve one in the insertion re, which is especilly eneficil in the femor of smll stture ptients. c Fig 4 c The LATERAL RELIEF CUT design of the nil () voids impingement of the lterl cortex (). The BUMP CUT design of the proximl hole for the hed element (c) provides improved ftigue strength compred to existing nils of similr size. Fig 5 c Illustrtion of the rdiolucent iming rm (). Nil rottion hs to e djusted until the two rdiogrphic lines on the insertion hndle re prllel to oth the femorl shft nd nil. This ensures tht the guide wire is in the correct position in the lterl view (, c). As prerequisite for this, true lterl projection of the proximl femur (ie, 180 ngle of the femorl neck nd shft) hs to e estlished y rotting the C-rm from neutrl position to out 15 to compenste for the nteversion of the hed nd neck. Evluting nil ftigue is key stge in the preclinicl nlysis of new implnt designs. The medin ftigue limit for the TFNA nil ws 24% higher thn tht of the Gmm 3 nil nd 47% higher thn tht of the InterTAN nil. This increse in ftigue strength is likely ttriuted to the use of high-strength Ti-Mo (Ti-15Mo) lloy nd the design fetures of the nil (Fig 4c). Suoptiml plcement of the hed element Aprt from the newly introduced nil design fetures, which help to mintin good reduction, it is lso essentil to plce the hed element in the correct position of the femorl hed to void cut-out or cutthrough. Numerous studies hve demonstrted tht center/center position of the hed element ensures the est clinicl outcome. Multiple instrument fetures, including multi hole drill sleeve for the fcilittion of precise nil entry nd iming ids to ccommodte the plcement of the hed element guide wire in the correct position hve een dded to the TFNA system to enle ccurte implnt plcement. The insertion hndle is rdiolucent nd hs rdiogrphic indictors to help the surgeon with exct guide wire plcement for hed element positioning in the lterl view (Fig 5). This feture, together with the guide wire iming device, which checks guide wire position in the AP view, is influentil in the plcement of the guide wire in the center/center position of the femorl hed. It lso helps to reduce the numer of imging mneuvers nd x-ry shots required. c AOTK SYSTEM INNOVATIONS 2015

9 IM NAILING 7 Fig 6 The TFNA Helicl Blde () nd TFNA Screw () hve n olique lterl end tht lies flush with the lterl cortex, therefore reducing hed element protrusion into the soft tissues. Both the helicl lde nd screw re ville in lengths of 70 to 130 mm with 5 mm increments. Cut-out nd cut-through Multiple iomechnicl nd finite element (FE) studies hve illustrted tht the purchse of implnts in osteoporotic one is compromised. A lde-shped hed element nd ugmenttion hve een proven to enhnce implnt stility nd this is especilly significnt in society with growing geing popultion nd incresing cses of osteoporosis. Hving modulr niling system, which comprises screw, lde, nd ugmenttion, offers distinct dvntge when ddressing specific frcture situtions, locl one qulity, nd issues like suoptiml reduction nd implnt plcement. The surgeon hs the option to choose etween the TFNA Helicl Blde nd the TFNA Screw (Fig 6) for hed element fixtion, which ccommodtes differing surgicl preferences nd fcilittes hospitl stndrdiztion. It is recommended to use the helicl lde in cses of poor one qulity ecuse it llows for one compction round the hed element nd voids the one loss tht occurs with the drilling nd insertion of the stndrd hip screw. Optionl holes in the lde or screw enle ugmenttion of the hed element in cses where dditionl fixtion is required (only in countries where ugmenttion is pproved from regultory perspective). The enefit nd efficcy of ugmenttion is of prticulr significnce in n off-center position of the hed element. Leg shortening nd lterl protrusion of the hed element For resons of verstility, the new TFNA system offers two locking options (Fig 7). The first option locks rottion of the hed-neck element. The second option inhiits lterl sliding of the hed-neck element, thus preventing shortening of the femorl neck nd lterl protrusion of the hed element. Fig 7 A uilt-in locking mechnism () fcilittes rottionl locking (), which llows sliding of the screw or lde hed element while locking rottion. Sttic locking cn e chieved y tightening the locking mechnism with torque limiter to crete fixed construct with no hed element movement. The sttic locking mode mintins the femorl neck length.

10 8 IM NAILING Instrumenttion nd implnt removl The QUICK CLICK self-retining technology is designed for esier nd sfer ttchment of the nil to the insertion hndle (Fig 8). An optionl percutneous set with lrger instruments including protection sleeve nd insertion hndle re ville for lrge stture ptients. Another importnt feture of the instrumenttion is its ility to enle interfrgmentry compression when used in conjunction with compression nut fter rottion hs een locked. Mtching internl threds in implnt nd removl instruments fcilitte implnt removl. Fig 8 The self-retining technology is used etween the connecting screw nd ll hexgonl screwdriver s well s etween the insertion hndle nd nil to reduce the risk of ccidentl detchment nd susequent de-steriliztion. Nil lengths nd distl locking The new nil system comprises short nils (lengths 170 mm, 200 mm, 235 mm) with distl nil dimeters of 9, 10, 11 nd 12 mm s well s long nils (lengths 260 to 480 mm in 20 mm increments) with distl nil dimeters of 9, 10, 11, 12 nd 14 mm. Such choice should ddress rod rnge of ptient ntomy. All nils re ville in Cput-Collum- Diphysel (CCD) ngles of 125, 130 nd 135. The long nil provides three distl locking options including unique olique distl hole tht hs n offset ngle of 10 to more ppropritely trget stronger one in the condyles. Multi-plnr locking lso offers incresed stility. The TFNA system is indicted for: Stle nd unstle pertrochnteric frctures Intertrochnteric frctures Bsl neck frctures Comintion of pertrochnteric, intertrochnteric, nd sl neck frctures. The long nils re dditionlly indicted for: Sutrochnteric frctures Pertrochnteric frctures with shft frctures Pthologic frctures (including prophylctic use) in oth trochnteric nd diphysel regions Long sutrochnteric frctures Proximl or distl nonunions, mlunions, nd revisions. References 1 Bzylewicz DB, Egol KA, Kovl KJ. Corticl encrochment fter cephlomedullry niling of the proximl femur: evlution of more ntomic rdius of curvture. J Orthop Trum Jun; 27(6): Roerts JW, Liet LA, Wolinsky PR. Who is in dnger? Impingement nd penetrtion of the nterior cortex of the distl femur during intrmedullry niling of proximl femur frctures: preopertively mesurle risk fctors. J Trum Acute Cre Surg Jul; 73(1): Schmutz B, Kmiec S, Wullschleger M, et l. 3D computer grphicl ntomy study of the femur: sis for new nil design. 2nd AOTrum Asi Pcific Scientific Congress & TK Experts Symposium. My 2014; Seoul. AOTK SYSTEM INNOVATIONS 2015

11 IM NAILING 9 Cse provided y Michel Bluth, Innsruck, Austri Cse 1: Fll t home An 83-yer-old femle ptient sustined 31-A.2.2 frcture of the right proximl femur fter fll t home (Figs 9 10). Intropertive nd postopertive imges re shown (Figs 11 13). Fig 9 AP x-ry. Fig 10 Injury imges. Fig 11 c AP views of the closed reduction (), mesurement of the CCD ngle, in this cse 130 (), nd the finl result with the lde in center/center position nd the lde tip pproximtely one cm from the joint line (c). The distl end of the lde is flush with the lterl femorl cortex. c Fig 12 Lterl views fter closed reduction with slight extension mllignment (). The finl result, with slightly eccentric position of the lde (). Fig 13 Postopertive imges t dy 3 fter moiliztion.

12 10 IM NAILING Cse provided y Michel Bluth, Innsruck, Austri Cse 2: Pertrochnteric frcture A 98-yer-old femle ptient sustined pertrochnteric frcture of the left proximl femur due to fll in her nursing home (Fig 14). There ws significnt pin nd coxrthritis in the right hip, nd hypertension. Surgery ws performed within 24 hours. There ws n indiction for ugmenttion due to the instility of the frcture. The ptient dditionlly suffered from osteoporosis nd dementi. c Fig 14 c Injury imges. Fig 15 c Intropertive imges. Good reduction nd implnt plcement. Peri-implnt ugmenttion with PMMA V Plus cement to offer incresed stility. Implnts used: TFNA (170/10), 130 lde (85 mm), 4 ml of VERTECEM V+ cement. c Fig 16 Postopertive x-rys. Fig 17 Follow-up x-rys fter few dys. There ws susidence of the frcture with controlled sliding of the lde. AOTK SYSTEM INNOVATIONS 2015

13 TRAUMA, UPPER EXTREMITY 11 Mrtin Jeger, Norert Südkmp TRAUMA, UPPER EXTREMITY PHILOS Augmenttion post lunch product review Proximl humerl frctures re frequent injuries in the elderly. Despite medicl dvnces, these injuries remin constnt chllenge nd s result, severl predictors for the filure of surgicl intervention hve een identified [1, 2]. A common risk fctor is poor one qulity, which cn impede the fixtion of implnts. A recent development to overcome this prolem is the ugmenttion of screws used for open reduction nd internl fixtion with PHILOS (Proximl Humerl Internl Locking System) (Fig 1). This technology is well known nd hs een proven success. Recent iomechnicl studies hve demonstrted the enhnced nchorge of PHILOS with ugmenttion in the presence of low-density-one [3 5]. Low het distriution nd its potentil consequences hve lso een tested [6]. Fig 1 PHILOS ugmenttion. References 1 Südkmp NP, Audigé L, Lmert S, et l. Pth nlysis of fctors for functionl outcome t one yer in 463 proximl humerl frctures. J Shoulder Elow Surg. 2011; 20: Krppinger D, Bizzotto N, Riedmnn S, et l. Predicting filure fter surgicl fixtion of proximl humerus frctures. Injury. 2011; 42: Röderer G, Scol A, Schmölz W, et l. Biomechnicl in vitro ssessment of screw ugmenttion in locked plting of proximl humerus frctures. Injury 2013; 44: Kthrein S, Krlinger F, Bluth M, et l. Biomechnicl comprison of n ngulr stle plte with ugmented nd non-ugmented screws in newly developed shoulder test ench. Clin Biomech (Bristol, Avon). 2013; 28: Unger S, Erhrt S, Krlinger F, et l. The effect of in situ ugmenttion on implnt nchorge in proximl humerl hed frctures. Injury. 2012; 43: Blzejk M, Hofmnn-Fliri L, Büchler L, et l. In vitro temperture evlution during cement ugmenttion of proximl humerus plte screw tips. Injury. 2013; 44: The first cse using PHILOS ugmenttion ws performed in Jnury The prctice of electing to ugment PHILOS with PMMA cement hs since developed into routine procedure in ptients ged 65 nd ove with poor one qulity. The use of ugmenttion in elderly ptients with mrked vrus nd vlgus displced proximl humerl frctures is prticulrly evident. However, when considering ugmenttion in cses involving hed-split frcture, cution is required in order to void the risk of intrrticulr cement distriution. The sic principles of ntomic reduction nd ngulr stle fixtion remin the sme. Following the completion of lekge test using rdiopque contrst dye, nd susequent confirmtion tht no joint perfortion is evident, ugmenttion is performed using Trumcem V under fluoroscopic controls. The ugmenttion should tke no more thn 10 minutes surgery time. Upper Extremity Expert Group study The AO Upper Extremity Expert Group (UEEG) initited prospective rndomized interntionl multicenter study in order to investigte the outcome of PHILOS ugmenttion in the presence of displced three nd four-prt proximl humerl frctures. The initil results revel promising outcome when using this new technique. Of course, not ll prolems in the tretment of proximl humerl frctures re resolved with ugmenttion. Some issues, such s multiple frgmented tuerosities nd the development of vsculr necrosis remin constnt chllenge.

14 12 TRAUMA, UPPER EXTREMITY Cses provided y Mrtin Jeger, Freiurg, Germny Cse 1: 79-yer-old with four-prt disloction A 79-yer-old mn suffered four-prt disloction frcture fter fll from stnding height (Fig 2). Closed reduction ws chieved in the technique ccording to Stimson (Fig 2). Intropertive fluoroscopic controls document n ntomic reduction nd internl fixtion with PHILOS (Fig 3). Intropertive lekge testing with rdiopque contrst dye ws performed (Fig 4). The Trumcem V ws then prepred (Fig 5). Intropertive screw ugmenttion with Trumcem V ws then conducted (Fig 6). Finl fluoroscopic controls document n extrrticulr cement distriution (Fig 7). The 3-month postopertive x-rys re shown (Fig 8). Fig 2 Imges of the injury () nd performing closed reduction (). c d e f g h Fig 3 h Intropertive imges introducing the PHILOS implnt. Fig 4 Intropertive lekge testing. Fig 5 d Trumcem V preprtion. c d AOTK SYSTEM INNOVATIONS 2015

15 TRAUMA, UPPER EXTREMITY 13 c Fig 6 c Screw ugmenttion. Fig 7 Finl fluoroscopic controls. Fig 8 c Postopertive x-rys. c Cse 2: 94-yer-old mn fell A 94-yer-old mle ptient suffered four-prt disloction frcture fter fll from stnding height (Fig 9). Closed reduction ws chieved in the technique ccording to Stimson (Fig 9). The intropertive fluoroscopic controls document n ntomic reduction nd fixtion with PHILOS ugmenttion (Fig 10). The postopertive x-rys t dy 0, dy 2, week 6, nd month 6 demonstrte n incresing secondry disloction of the greter tuerosity. Note tht the humerl hed segment remins t its initil ntomic position (Fig 11). Fig 9 Imges of the injury () nd closed reduction (). A reverse shoulder rthroplsty ws performed (Fig 12). Imges showing the clinicl outcome 8 months fter the rthroplsty re shown (Fig 13).

16 14 TRAUMA, UPPER EXTREMITY Fig 10 c Intropertive fluoroscopic controls. c c d Fig 11 d Postopertive imges. Fig 12 X-rys demonstrte the sitution 8 months fter conversion to reverse shoulder rthroplsty. Fig 13 d Clinicl outcome 8 months postopertive. c d AOTK SYSTEM INNOVATIONS 2015

17 NOW AVAILABLE! Jesse B Jupiter Fiesky Nuñez Rento Fricker Mnul of Frcture Mngement Hnd The mngement of trumtic nd reconstructive prolems of the hnd hs ecome n ever more complex field. Advnces in sic science nd technology together with growth in clinicl expertise hve resulted in recent drmtic chnges in mny of the implnts, instruments, nd techniques used in modern hnd surgery. Mnul of Frcture Mngement Hnd y Jesse Jupiter, Fiesky Nuñez, nd Rento Fricker is principlly cse-sed puliction designed to instruct nd introduce new technologies nd methods to oth new nd experienced hnd surgeons. The ook s key fetures include: Detiled cse descriptions nd recommended tretment options for wide vriety of frcture nd injury types, from spirl to trnsverse, nd multifrgmentry to mlunion, involving the proximl middle nd distl phlnges of the fingers nd thum, the metcrpls, nd the joints More thn 2250 high-qulity illustrtions nd clinicl imges Access to n online video lirry of dozens of hnd surgery pproches nd clinicl demonstrtions. Using the principles nd techniques developed y leding surgicl specilists from the renowned AO Foundtion, AOTrum is proud to ring you this exciting updte, which will e n idel resource for trum nd orthopedic surgery professionls, residents in trining, nd medicl students round the world. MediCenter.thieme.com Numer of pges: 568 Numer of illustrtions nd imges: 2250 ISBN: e-isbn: Puliction dte: Decemer 2015 Retil price: EUR / USD The e-ook is ville t

18 16 TRAUMA, LOWER EXTREMITY Andrew Snds, Michel Cstro, Jun Gerstner, Leslie Grujic, Stefn Rmmelt, Michel Swords, In Winson TRAUMA, LOWER EXTREMITY VA LCP Midfoot/Hindfoot System The new Vrile Angle Locking Clcnel Plte (Fig 1) is indicted for trditionl plte fixtion of clcneus frctures. The enefits of such locking technology include n ility to insert screw t the est ngle for the most optiml purchse in smller one frgments nd minimized risk of joint penetrtion in cses where frcture ptterns demnd screw plcement in close proximity to n rticulr surfce. Fig 1 VA Locking Clcnel Plte. The new Vrile Angle Locking Anterolterl Clcnel Plte (Fig 2) is indicted for minimlly invsive posterior clcneus frcture fixtion in comintion with 3.5 mm or 4.0 mm cortex screws. The Anterolterl Clcnel Plte is used to support the rticulr surfce of the sutlr joint. The dditionl screws re used to fix the frgments of the clcneus required y the specific frcture pttern. The numer nd size of screws used to fix the frcture is dependent upon the frcture pttern, one qulity, nd the weight of the ptient. A minimum of three screws should e used in divergent positions to provide sufficient stility. Fig 2 VA Locking Anterolterl Clcnel Plte. Medil column fusion The new Vrile Angle LCP Medil Column Fusion Plte system (Fig 3) is indicted for dvnced stiliztion nd fusion in Chrcot foot nd severe rthritis. The system comprises pltes for ppliction on the dorsomedil, medil, nd plntr spects of the foot s well s medil plcement with tlus extension. Using the compression/distrction instrument enles independent compression of selected joints. Compression/Distrction Device set The Compression/Distrction Device is very verstile instrument tht cn e used cross numerous pplictions to reduce frctures or optimlly lign ones in preprtion for fusion. Multiple devices cn e used in comintion for multifrgmentry frctures or for the control nd lignment of severl ffilited ones. This set is not limited to use in the foot nd nkle nd is regulrly used s n intropertive holding device for frctures nd osteotomies to otin optiml lignment prior to fixtion. Fig 3 VA LCP Medil Column Fusion Plte. Note The VA Locking Anterolterl Clcnel Plte is witing regultory pprovl outside the USA. AOTK SYSTEM INNOVATIONS 2015

19 TRAUMA, LOWER EXTREMITY 17 Cse provided y Michel Swords, Est Lnsing, USA Cse 1: Ldder fll A 58-yer-old womn (Fig 4), who hd fllen from ldder 9 weeks erlier, hd indictions of mlunited frcture nd ws referred to the clinic y fmily physicin. The mlunion hd to e treted with n osteotomy to reconstruct the joint nd regin norml function. The osteotomy ws fixed with the VA Locking Clcnel Plte (Figs 5 nd 6). Fig 4 Preopertive ptient x-rys. Fig 5 Intropertive imge of the procedure. Fig 6 Postopertive imges showing the VA Locking Clcnel Plte.

20 18 TRAUMA, LOWER EXTREMITY Cse provided y Andrew Snds, New York, USA Cse 2: 70-yer-old ptient A 70-yer-old femle ptient (Fig 7) hd long history of incresing pinful deformity of her foot. She lso noted incresing git prolems. There ws no history of initil trum. The exmintion showed severe rigid fltfoot deformity. An extended triple rthrodesis ws performed. Medilly, the new Medil Column Plte ws used, securing the tlonviculr, nviculocuneiform, nd trsomettrsl joints (Fig 8). The X-plte is lterl nd secured the clcneocuoid joint. Two 7.3 mm screws were used to secure the sutlr joint. Fig 7 Ptient imges. Fig 8 Postopertive imges. Imge provided y Jun Gerstner, Cli, Colomi Cse 3: Compression/Distrction Device The picture shows the use of the Compression/Distrction Device in the midfoot (Figs 9 nd 10). Fig 9 Compression/Distrction Device. Fig 10 Compression/Distrction Device eing used. AOTK SYSTEM INNOVATIONS 2015

21 CMF 19 Crl-Peter Cornelius, John Hrdemn CRANIOMAXILLOFACIAL MtrixWAVE MMF Mxillomndiulr fixtion (MMF) is vitl step in the mngement of mxillofcil trum. In order to fixte frctures correctly nd chieve dequte frcture reduction, the mxillry nd mndiulr dentition must e put into occlusion. Vrious methods cn e used to chieve MMF including rch rs secured with interdentl wires nd intermxillry fixtion (IMF) screws, ut these methods hve severl disdvntges. Fig 1 MtrixWAVE pltes re ville in two heights, short () nd tll (). The imge shows the plte correctly oriented for ppliction to the mxill. Pltes re inverted for fixtion to the mndile. Limittions of rch rs The limittions of rch rs include prolonged operting room time nd expense to pply nd remove the device; difficulty in frgment lignment once the rch r hs een put in plce; the risk of needle stick type injuries; difficulty in mintining orl nd gingivl hygiene; nd the risk tht tightened wires my cuse ischemic necrosis of the mucos nd periodontl memrne, cusing tooth loss. Spce occupied y mucos Limittions of IMF screws The limittions of IMF screws include posterior mndile frctures eing more prone to poor reduction nd susequent mlocclusion; nd the risk of unnoticed lingul tilting of frgments due to the distnce etween nchoring points. Fig 2 The MtrixWAVE plte should e ttched with 1.85 mm self-drilling locking screws with n ccessile screw hed. The screws re ville in 6.0 mm or 8.0 mm thred length. By virtue of the locking mechnism, the screws do not touch the mucosl tissues, therey voiding complictions cused y compression nd ischemi. Design fetures nd enefits MtrixWAVE MMF (Figs 1 7) is novel one-orne MMF system tht comines the strength nd rigidity of rch rs with the speed nd simplicity of IMF screws, nd consists of wve shped plte tht is ttched to the mndile nd mxill with self-drilling locking screws (Fig 2). The plte is dptle nd cn e expnded horizontlly (Fig 3) to enle screw hole plcement in the optiml loction to void tooth roots nd nerves. The locking mechnism voids compression nd ischemi y keeping the plte wy from the mucosl tissues. The dentl rches re rought into occlusion y wiring round the plte hooks nd/or ccessile screw heds. The self-drilling locking screws sit proud to the plte. This minimizes soft-tissue growth over the screw, nd provides dditionl nchor points for optionl ridle wires. Upon insertion, screws cn e ngled t up to 15. Fig 3 Horizontl expnsion of the MtrixWAVE plte prior to ppliction. Following ppliction nd wiring, the wve plte pttern llows the lignment of one segments to e djusted y crimping without repositioning the screws. The plte is ville in two heights to llow the positioning of the hooks t the level of the tooth equtors ccording to individul ptient ntomy, nd to ccommodte the use of rigid internl fixtion (Fig 1).

22 20 CMF Mxillomndiulr fixtion cn e chieved rpidly using the Mtrix- WAVE plte. Removl is simple, nd cn e done in non-or setting. The MtrixWAVE plte design elimintes the need for circumdentl wiring. This hs severl dvntges, including reduced risk of needle stick-like injuries nd reduced risk of tooth loosening. Additionlly, the MtrixWAVE MMF system covers less tooth surfce, llowing etter ccess to the teeth nd periodontl tissues for clening. The design of the plte mximizes ptient comfort, s it hs rounded smooth edges. The screw heds re lso rounded, nd the plte hooks cn e ent towrds the gingiv fter wiring. Fig 4 MtrixWAVE plte djustment to lign loction of remining screws. Indictions The MtrixWAVE MMF system is indicted for the temporry stiliztion of mndiulr nd mxillry frctures nd osteotomies in dults nd dolescents (ge 12 yers nd higher) with full permnent dentition. The system is intended to mintin proper occlusion during intropertive one fixtion nd postopertive one heling (pproximtely 6 8 weeks). The system ffords the ility to lign one frgments. However, MtrixWAVE MMF pltes do not hve tension nd function, unless dditionl ridle wire loops re used on the screw heds cross the frcture line. Fig 5 Insertion of remining screws through the plte into the inter-root spces, with enggement of the locking threds. Fig 6 Appliction of wire, using plte hooks s nchor points. Screw heds cn serve s dditionl nchor points. Fig 7 Completed wiring. MMF wire ligtures secure the dentl occlusion with ridle wire, providing tension nding cross the frcture line. AOTK SYSTEM INNOVATIONS 2015

23 CMF 21 Cse provided y John Hrdemn, Florid, USA Cse: Left mndiulr ngle frcture cused y ssult A 28-yer-old white mle ptient ws ssulted, suffering left mndiulr ngle frcture (Fig 8). The frcture ws prestilized with the MtrixWAVE system nd then fixted with 4-hole miniplte 2.0 on the superior order nd 4-hole ngulted universl frcture plte 2.4 long the inferior order. A preexisting nterior open ite ws noted nd confirmed with the ptient prior to presenttion to the operting ren. Fig 8 Preopertive coronl CT slice, showing left mndiulr ngle frcture. The MtrixWAVE plte ws ttched to the mxill with screw plcement in the inter-root spces (Fig 9). A second MtrixWAVE plte ws ttched in corresponding position to the mndile, with screw plcement in the inter-root spces (Fig 10). Wires were plced round the plte hooks to ring the dentl rches into occlusion. Note the preexisting nterior open ite (Fig 11). Creful djustment of the MtrixWAVE plte nd wiring in the region of the mndiulr frcture llowed the one frgments to e precisely ligned without the requirement for screw repositioning (Fig 12). The postopertive pnormic x-ry (Fig 13) shows the two MtrixWAVE pltes in situ, with other pltes used to fixte the left mndiulr ngle frcture. Note tht portion of the Mtrix- WAVE plte ws removed from the left molr region in the mndile (Fig 13). Fig 9 The MtrixWAVE plte ws ttched to the mxill, with screw plcement in the inter-root spces. Fig 10 A second plte ws ttched in corresponding position to the mndile. Fig 11 Plcement of wires round the plte hooks. Fig 12 Adjustment of the plte nd wiring in the region of the frcture. Fig 13 Postopertive pnormic x-ry showing the completed fixtion.

24 22 NEURO Geoffrey Mnley NEURO MtrixNEURO Preformed Mesh MtrixNEURO Preformed Mesh is n ntomiclly contoured rigid mesh implnt for the reconstruction of medium to lrge crnil defects. It is intended for use in the fixtion of crnil ones in procedures such s reconstruction, frcture repir, crniotomies, nd osteotomies. Fig 1 Temporl preformed mesh. Design Fetures nd Benefits Unlike contourle reconstruction meshes, which must e ent to shpe in the OR, MtrixNEURO Preformed Mesh is ville in rnge of ntomicl shpes to fit temporl (Fig 1), fronto-temporo-prietl (Fig 2), nd frontl res (Fig 3). The preformed nture of the mesh reduces ending nd overll procedure time (compred to MtrixNEURO Reconstruction Mesh) in the operting room. The specific contouring of the mesh is sed on dt from clinicl CT study of 80 ptients [1], which estlished sttisticl men of ntomicl crnil fetures. The development of the full rnge of MtrixNEURO Preformed Mesh implnts ws informed y dt tht identified the most common loctions nd sizes of crnil defects. The implnts re mnufctured using proprietry process designed to crete smooth contours without ending or kinking. The mesh is designed for use with MtrixNEURO self-drilling screws. References 1 Kmer L, Noser H, Hmmer B. Antomicl ckground for the development of preformed crnioplsty implnts. J Crniofcil Surgery. 2013: Fig 2 Fronto-temporo-prietl (FTP) preformed mesh. Fig 3 Frontl preformed mesh. AOTK SYSTEM INNOVATIONS 2015

25 NEURO 23 Christin Mtul SYNTHECEL Dur Repir SYNTHECEL Dur Repir (Figs 1 2) is durl sustitute sed on iosynthesized cellulose technology. It is designed for the repir of dur mter during crnil or spinl surgery, following trumtic, neoplstic, or inflmmtory dmge. Fig 1 SYNTHECEL Dur Repir cn e used s durl sustitute following neoplstic dmge. c d Fig 2 d Mteril composition. Composed of iosynthesized cellulose nd wter, SYNTHECEL Dur Repir is similr in thickness to humn dur. Lyers of iosynthesized cellulose (high mgnifiction). c Interconnected cellulose fiers tht comprise SYNTHECEL. d Cellulose fiers re nturlly produced y Glucocetocter xylinus. Unmet clinicl needs in durl repir Mterils currently used for dur replcement include humn tissues (eg, pericrnium or fsci lt), niml tissues, polymers, nd iosynthetic sustnces. However, use of these mterils cn e prolemtic. Autologous tissue grfts cn perform well s they do not provoke inflmmtory or immunologicl rections, ut cn present difficulties in chieving wtertight closure nd in the formtion of scr tissue. Autologous tissues my provide insufficient grft mteril to close lrge durl defects nd cuse moridity t the hrvest site. Synthetics hve een ssocited with deep wound infections, s polymers cn ecome chroniclly colonized. Xenogrfts cn cuse dverse effects such s grft dissolution, encpsultion, foreign ody rection, scrring, or the formtion of dhesions. Following decompressive crniectomy, dhesions cn develop etween dur mter, cortex, temporlis muscle, nd gle. Such dhesions cn ct s epileptic foci nd cn increse the surgicl risk of susequent crnioplsty. Additionlly, xenogrfts hve een ssocited with the trnsmission of virl infections nd hydrodynmic complictions including persistent cererospinl fluid (CSF) lekge, pseudomeningocele, septic meningitis, nd delyed hydrocephlus. To function effectively, durl sustitutes should: Prevent CSF lekge Minimize risk of infection Hve mechnicl properties similr to humn dur nd good intropertive hndling properties Hve no hrmful foreign ody rection Be redily ville Be storle Be iocomptile.

26 24 NEURO Development of SYNTHECEL Dur Repir SYNTHECEL ws developed s superior durl sustitute, with the im to eliminte or reduce mny of the dverse events mentioned ove. SYNTHECEL Dur Repir is n implnt sed on iosynthesized cellulose technology. Cellulose pellicles of specified weight nd cellulose content re produced y the cterium Glucocetocter xylinus when propgted in nutritive culture medi. Fig 3 Investigtionl device exemption (IDE) intropertive imge showing durl repir using SYN- THECEL Dur Repir (courtesy of Brrow Neurosurgicl Assocites). Fig 4 Demonstrting the product s strength () nd sutureility (). Comprised of nonwoven, interconnected cellulose fiers, SYNTHECEL hs excellent tensile strength nd functions s mechnicl lyer to protect nd repir durl defects while preventing CSF lekge (Fig 3). SYNTHECEL is immunologiclly inert, llows heling without dhesion formtion, nd voids the complictions inherent in the use of utologous tissue in durplsty. SYNTHECEL is nonniml derived, mening there is no risk of trnsmissile diseses. Clinicl performnce of SYNTHECEL Dur Repir Clinicl studies hve shown tht SYNTHECEL Dur Repir is not inferior to other commercilly ville durl replcement products in terms of surgicl site infection, wound heling ssessment, or rdiologic endpoints (sence of pseudomeningocele nd CSF fistul) [1]. Furthermore, SYNTHECEL ws shown to e superior in terms of product strength, sutureility nd sel qulity (Fig 4). Indeed, prospective rndomized controlled study found SYNTHECEL to exhiit superior strength nd sutureility (Figs 5 6) [1]. In terms of surgicl hndling, SYNTHECEL is similr in thickness to humn dur nd conforms esily to the rin. References 1 Rosen CL. Results of the prospective, rndomized, multicenter clinicl tril evluting iosynthesized cellulose grft for repir of durl defects. Neurosurgery Nov; 69(5): ; discussion Fig 5 SYNTHECEL Dur Repir exhiited superior device strength compred to control group, in n ssessment of device hndling chrcteristics [1]. Fig 6 The product lso exhiited superior sel qulity compred to the control group [1]. AOTK SYSTEM INNOVATIONS 2015

27 POWER TOOLS 25 Stephen Lewis POWER TOOLS EG1 Electric High Speed Drill System The Anspch EG1 Electric High Speed Drill is high precision electric system designed for cutting nd shping one in the spine nd crnium (Fig 1). It hs rod rnge of pplictions within neurosurgery, neurotology surgery, skull se surgery, otolryngology surgery, nd spinl surgery. Fig 1 The EG1 Electric High Speed Drill system, including electric console nd foot control. The drill hs vrile operting speed of 10,000 to 80,000rpm nd offers power output 30% higher thn existing Anspch high speed drills (eg, XMx nd emx2plus systems), while operting t miniml sound levels. It hs smll, lightweight hndpiece to minimize hnd ftigue (Fig 2), miniml strt-up kick, low virtion for incresed cutting precision, nd n integrted ir cooling system. The drill is verstile with wide rnge of dissection tools (Fig 3), including crniotomes, urrs, nd stright or ngled ttchments. The coupling mechnism is simplified (plce nd lock ttchments nd push to lock dissection tools) for greter ese of use nd effortless ssemly. Other fetures include new irrigtion tue, hose swivel elow, nd incresed reliility. Fig 2 The ircooled hndpiece, showing the coupling system for ttchments nd dissection tools. Fig 3 The portfolio of Anspch ttchments for the EG1 Electric High Speed Drill, including stright ttchments of vrious lengths, hevy duty ttchments of vrious lengths, crniotomies, ngle ttchments, nd perfortor driver.

28 26 SPINE Frnk Kndzior, Mrten Spruit SPINE Fig 1 Screws cross the fcet joint. Fcet Wedge Spine System The tretment of chronic low ck pin or ny neurologicl deficit due to degenertive conditions of the spine is well estlished. However, there remins no cler consensus on when 360 fusion is required or when postero lterl fusion (PLF) will suffice. In ptients with high degree of degenertion nd instility, comined nterior nd posterior column fusion is often pproprite. When the degenertion is less nd there is miniml instility, PLF my e more suitle. With mny of these surgicl tretments, the posterior fixtion my e performed with trnslminr fcet screws (TFS) [1]. Posterior fixtion of the lumr motion segments with TFS is less invsive option thn the more commonly used pedicle screws nd rods. It is lso ccurte to suggest tht this technique helps to promote miniml soft tissue dmge. Fig 2 Trnsfcet pedicle screw. History of Trnslminr Fcet Screws (TFS) Use of TFS ws first descried y King [2] in His technique involved the insertion of short screws cross the fcet joint (Fig 1). This pproch ws further modified y Boucher [3] in 1959 through the use of longer screw, the trnsfcet pedicle screw, directed towrds the pedicle (Fig 2). Fig 3 Trnslminr screw fixtion. The pproch most commonly used tody, however, is Mgerl s technique, which involves the use of n even longer screw [4]. This screw enters through the se of the spinous process, trverses the length of the lmin, crosses the fcet joint, nd fixtes in the se of the trnsverse process. This procedure, trnslminr screw fixtion, is discussed extensively in the literture [5 14] (Fig 3). A second option for the chievement of primry stility is y locking the fcet joints with fcet interference screw (FIS) (Fig 4). Biomechnicl investigtions hve illustrted similrity etween FIS fixtion nd TFS fixtion in terms of primry stility. Fig 4 Fcet interference screw. Biomechnicl studies [1, 15 17] hve provided evidence supporting the use of TFS s fixtion technique for spinl motion segments. Fusion rtes ssocited with TFS rnge from 83% to 100% [5, 7, 11, 18-20]. The numer of re-opertions for vrious resons rnges from 2-37% [5 7, 13, 21]. TFS fixtion is lso ssocited with smller incisions, ese of procedure nd lerning curve, less instrumenttion, nd lower costs [7, 9, 12, 19, 22, 23]. Postero lterl fusion with TFS fixtion should, similrly to pedicle screw fixtion, only e performed with n intct nterior column. The disc therefore needs to e intct. AOTK SYSTEM INNOVATIONS 2015

29 SPINE 27 Fcet Wedge design concept, enefits, nd dvntges The Fcet Wedge (FW) spinl system ws developed to enhnce the dvntges lredy offered y the TFS. The intended use, indictions, nd contrindictions for FW fixtion re very similr to TFS fixtion. Fcet Wedge is intended for the fixtion of the spine s n id to fusion through the immoiliztion of the fcet joints, with or without one grft, t single or multiple levels, from L1 to S1. It cn e inserted through minimlly invsive pproch either to ugment other fusion techniques or s stnd-lone device for cses without segmentl instility. The FW system is designed s press fit lock with friction rils to stop trnsltionl motion in the fcet joints. In ddition to the wedge, two screws re inserted divergently t 30 ngles in order to increse pull out resistnce. The dvntge of the FW design over the TFS is the direct visuliztion of the fcet joint, which fcilittes ccurte implnt insertion nd my reduce the risk of dmge to neurl structures. The specific instruments used in conjunction with the FW llow fcet joint preprtion (eg, crtilge removl) to improve the likelihood of successful fusion. Preclinicl iomechnicl tests demonstrte tht the iomechnicl properties (stiffness nd ROM) of FW re comprle to pedicle screw nd rod fixtion, s well s TFS fixtion in ll motion directions. Indictions Stnd-lone (ilterl) in situ fcet fusion with or without decompression Fcet rthritis: fixtion nd fusion of fcet joint Supplementry fixtion fter nterior cge or nonunion of ALIF Supplementry contr lterl fixtion fter MISS TLIF. Contrindictions Unilterl ppliction, except in comintion with pedicle screw fixtion on the contrlterl side Compromised fcets due to decompression techniques Spondylolisthesis Frcture or other instilities of the posterior elements Tumor Acute or chronic systemic or loclized spinl infections. Tips for sfety nd effectiveness The FW Spine System Risk Assessment identified tht incorrect plcement of the K-wire for rsp or FW positioning could result in dmge to soft tissue, neurl structures, or lrge lood vessels. A second risk involves the use of the fcet opener. Excessive force or inpproprite

30 28 SPINE mnipultion my lso led to the dmge of neurl structures. Severl control mesures re incorported into the Fcet Wedge system to minimize these risks nd plns re lso in plce to conduct study tht will mesure their occurrence. c Fig 5 c Fcet Wedge implnts. Description The Fcet Wedge spine system includes the following implnts nd fetures (Fig 5): Kirschner wire hole enles guided insertion over K-wire () Rils stop trnsltionl motion nd generte contct etween suchondrl one nd implnt () Low profile decreses muscle irrittion () Implnt shoulder tht controls insertion depth () Teeth keep the implnt in the desired position prior to screw insertion () Divergent ngulr stle locking screws for primry fixtion () Vrious implnt sizes to ccommodte ptient ntomy () Perfortions crete optiml fusion conditions (c). References 1 Rthonyi GC, Oxlnd TR, Gerich U, et l. The role of supplementl trnslminr screws in nterior lumr interody fixtion: iomechnicl study. Eur Spine J. 2008; 7(5): King D. Internl fixtion for lumoscrl fusion. J Bone Joint Surg Am. 1948; 30A(3): Boucher HH. A method of spinl fusion. J Bone Joint Surg Br. 1959; 41-B(2): Mgerl FP. Stiliztion of the lower thorcic nd lumr spine with externl skeletl fixtion. Clin Orthop Relt Res. 1984; (189): Aepli M, Mnnion AF, Gro D. Trnslminr screw fixtion of the lumr spine: long-term outcome. Spine (Phil P 1976). 2009; 34(14): Best NM, Ssso RC. Efficcy of trnslminr fcet screw fixtion in circumferentil interody fusions s compred to pedicle screw fixtion. J Spinl Disord Tech. 2006; 19(2): Gro D, Brtnusz V. A prospective, cohort study compring trnslminr screw fixtion with trnsforminl lumr interody fusion nd pedicle screw fixtion for fusion of the degenertive lumr spine. J Bone Joint Surg Br. 2009; 91(10): Gro D, Rueli M, Scheier HJ, et l. Trnslminr screw fixtion of the lumr spine. Int Orthop. 1992; 16(3): Heggeness MH, Esses SI. Trnslminr fcet joint screw fixtion for lumr nd lumoscrl fusion. Spine (Phil P 1976). 1991; 16(6 Suppl):S Humke T, Gro D, Dvork J, et l. Trnslminr screw fixtion of the lumr nd lumoscrl spine. A 5-yer follow-up. Spine (Phil P 1976). 1998; 23(10): Pvlov PW, Meijers H, vn Limeek, et l. Good outcome nd restortion of lordosis fter nterior lumr interody fusion with dditionl posterior fixtion. Spine (Phil P 1976). 2004; 29(17): ; discussion Reich SM, Kuflik P, Neuwirth M. Trnslminr fcet screw fixtion in lumr spine fusion. Spine (Phil P 1976). 1993; 18(4): Tuli J, Tuli S, Eichler ME, et l. A comprison of long-term outcomes of trnslminr fcet screw fixtion nd pedicle screw fixtion: prospective study. J Neurosurg Spine. 2007; 7(3): Tuli SK, Eichler ME, Woodrd EJ. Comprison of periopertive moridity in trnslminr fcet versus pedicle screw fixtion. Orthopedics. 2005; 28(8): Deguchi M, Cheng BC, Sto K, et l. Biomechnicl evlution of trnslminr fcet joint fixtion. A comprtive study of poly- Llctide pins, screws, nd pedicle fixtion. Spine (Phil P 1976). 1998; 23(12): ; discussion Ferrr LA, Secor JL, Jin BH. A iomechnicl comprison of fcet screw fixtion nd pedicle screw fixtion: effects of short-term nd long-term repetitive cycling. Spine (Phil P 1976). 2003; 28(12): Kornltt MD, Csey MP, Jcos RR. Internl fixtion in lumoscrl spine fusion. A iomechnicl nd clinicl study. Clin Orthop Relt Res. 1986; (203): Kng HY, Lee SH, Jeon SH, et l. Computed tomogrphy guided percutneous fcet screw fixtion in the lumr spine. J Neurosurg. Spine. 2007; 7(1): Sethi A, Lee S, Vidy R. Trnsforminl lumr interody fusion using unilterl pedicle screws nd trnslminr screw. Eur Spine J. 2009; 18(3): Shim CS, Lee SH, Jung B, et l. Fluoroscopiclly ssisted percutneous trnslminr fcet screw fixtion following nterior lumr interody fusion: technicl report. Spine (Phil P 1976). 2005; 30(7): Prk SH, Prk WM, Prk CW, et l. Minimlly invsive nterior lumr interody fusion followed y percutneous trnslminr fcet screw fixtion in elderly ptients. J Neurosurg Spine. 2009; 10(6): Foley KT, Holly LT, Schwender JD. Minimlly invsive lumr fusion. Spine (Phil P 1976). 2003; 28(15 Suppl):S Stonecipher T, Wright S. Posterior lumr interody fusion with fcetscrew fixtion. Spine (Phil P 1976). 1989; 14(4): AOTK SYSTEM INNOVATIONS 2015

31 SPINE 29 Cse provided y Frnk Kndzior, Frnkfurt, Germny Cse 1: 45-yer-old A 45-yer-old helthy mle ptient hd experienced lod dependent lower ck pin (LBP) for 6 yers, with no rdiculr pin nd no neurologic deficit. Multilevel fcet pthology is shown in Fig 6. Intropertive nd postopertive imges re shown (Figs 7 9). Fig 6 Preopertive CT scns. Fig 7 Intropertive imge. Fig 8 Postopertive X-rys t the 1-week follow-up. Fig 9 d The postopertive CT scns t the 1-week follow-up. c d

32 30 SPINE Cse provided y Frnk Kndzior, Frnkfurt, Germny Cse 2: 51-yer-old A 51-yer-old femle ptient hd een experiencing LBP for 3 yers (Fig 10). PNS right. Now L5 rdiculopthy left. c d Fig 10 d Preopertive CT scns. Fig 11 Intropertive imge. Fig 12 Postopertive x-rys t the 1-week follow-up. AOTK SYSTEM INNOVATIONS 2015

33 SPINE 31 Cse provided y Frnk Kndzior, Frnkfurt, Germny Cse 3: 66-yer-old A helthy 66-yer-old femle ptient hd een experiencing LBP for 5 yers (Fig 13). d c e Fig 13 e Preopertive CT scns. Fig 14 Postopertive x-rys. Fig 15 Postopertive CT scns. c d Fig 16 d Postopertive imges.

34 32 SPINE Cses provided y Mrten Spruit, Nijmegen, Netherlnds Cse 4: ALIF L4 5 nonunion A 40-yer-old mn hd ALIF L4 5 with SynFix 5 yers previously. He hd xil low ck pin. The CT scn showed locked pseudrtrosis (Fig 17). Nonopertive tretment filed. The tretment option ws ilterl Fcet Wedge t L4 5. Fcet wedge surgery A less invsive pproch ws used with Insight Retrctor, nd using the ilterl Fcet Wedge. No one grft. X-ry follow-up fter 3 months nd CT ssessment fter 6 months (Figs 18 19). Fig 17 Preopertive CT scn. Fig 18 X-rys t the 3-month follow-up. Fig 19 The CT scn t the 6-month follow-up. Cse 5: Degenertive scoliosis A femle ptient 66-yers-old hd ck pin, leg pin, nd degenertive deformity. The x-rys showed left convex degenertive scoliosis Co T12 L3 38. Nonopertive tretment filed. Tretment option ws posterior fusion T11 L5, with URS, Fcet Wedge L2 3 unilterlly. Fig 20 Postopertive x-ry. Fig 21 CT scn t the 6-month follow-up. URS/Fcet Wedge surgery A conventionl pproch for posterior correction ws tken, with indirect forminl decompression nd Fcet Wedge fusion (pex curve). Fcet Wedge introduction fter curve correction with rod in situ. X-ry follow-up initilly (Fig 20), with CT ssessment of Fcet Wedge fusion fter 6 months (Fig 21). AOTK SYSTEM INNOVATIONS 2015

35 SPINE 33 Innocent Njoku Jr, Roger Härtl Minimlly Invsive 2D Nvigtion-Assisted Spine Surgery in Est Afric Spinl surgery under Estern Africn circumstnces is techniclly demnding nd ssocited with significnt complictions such s lood loss, infection, nd wound rekdown. We report spinl trum cse tht ws performed using minimlly invsive surgery (MIS) nd nvigtion, nd hypothesize tht these newer techniques my enle surgeons to perform effective spinl surgery with miniml complictions nd good outcomes. In previous reports, we hve shown tht neurotrum is one of the most pprent neurosurgicl prolems in Afric, nd especilly so in Tnzni. The delivery of surgicl cre in these environments is mjor glol helth concern. Mcrosurgicl pproches in this context re ssocited with dverse effects such s muscle dmge, leeding, neuromusculr denervtion, nd incresed pin. Minimlly invsive surgery with nvigtion cn provide eneficil lterntive to open surgery prticulrly with respect to decresing infection rtes nd prolonged ed immoility. In ddition, MIS with nvigtion increses the ccurcy of pedicle screw plcement in the thorcic nd lumr spine, nd cn enle surgeons to perform complex opertions with fewer complictions y decresing postopertive pin, reducing infection rtes, nd overll moridity. During the 2014 hnds-on neurotrum course held in Dr Es Slm, we operted on 47-yer-old ptient with complex thorcic spine injury (Fig 1) using portle nvigtion system in conjunction with fluoroscopic imging. The surgery ws done under generl nesthesi with miniml lood loss nd no intropertive complictions (Fig 2). The ptient remined neurologiclly intct postopertively when compred to seline, nd ws dischrged two weeks following surgery. Imging performed one yer fter surgery demonstrtes dequte fusion with stle neurologicl exm (Fig 3). Despite the chllenges nd limittions involved in introducing complex minimlly invsive spinl surgery to under-resourced countries, such technologies offer importnt enefits to glol neurosurgicl helth. By performing the first MIS instrumenttion nd decompression procedures with 2D nvigtion together with our Tnznin prtners, we hve shown promising opportunities in spinl surgeries in emerging ntions.

36 34 SPINE Cse provided y Roger Härtl, New York, USA Cse: 47-yer-old from Tnzni The following imges re of 47-yer-old ptient with complex thorcic spine injury. Fig 1 Ptient imge. Fig 2 Intropertive imge. Fig 3 Postopertive imges t the 1-yer follow-up. AOTK SYSTEM INNOVATIONS 2015

37 SPINE 35 Pul Heini, Khi Lm Syncge Evolution Syncge Evolution represents new direct nterior or nterolterl interody cge for the lumr spine (Fig 1). The ntomicl design nd wide rnge of sizes (ville in vrious foot prints, heights, nd ngultions) fcilitte the correction of ny nterior interody prolem. Specific nd sophisticted instrumenttion enles sfe nd controlled ppliction of the implnt. Fig 1 The Syncge Evolution interody cge. Primry indictions for use include: Degenertive disc disese Revision procedures for postdiscectomy syndrome Pseudorthrosis or filed fusion Degenertive spondylolisthesis Isthmic spondylolisthesis Anterior column support for osteotomies. The Syncge Evolution spcer must e pplied in comintion with supplementry fixtion, such s n nterior plte system or pedicle screws. Contrindictions include: Verterl ody frctures Spinl tumours Osteoporosis Infection. Design fetures The design of the implnt offers incresed stility. Its pyrmidl teeth provide primry resistnce to implnt migrtion, nd the lrge grft volume llows for undercuts nd openings in struts to increse grft volume. The middle strut design llows for n improvement to rtio of grft volume to endplte contct, nd the dimond shped nterior nd nterolterl interfce provides for optiml force distriution from the implnt holder to the implnt. Other fetures include self-distrcting nose, which llows for ese of insertion. The tntlum rdiogrphic mrker pins enle visuliztion of the implnt position during insertion. Mteril: ville in PEEK with 0.8 mm tntlum mrker pins. c d e Fig 2 e The Syncge Evolution hs comprehensive portfolio of sizes nd ngles. The comprehensive nd competitive Syncge Evolution portfolio (Fig 2) osts n symmetric ntomicl shpe for more ptient specific implnts: Footprints: smll (32.0 x 25.0 mm), medium (36.0 x 28.0 mm), lrge (40.0 x 31.0 mm) Heights: from 9.0 mm to 19.0 mm (9.0 mm, 10.5 mm, 12.0 mm, 13.5 mm, 15.0 mm, 17.0 mm, 19.0 mm)

38 36 SPINE Angles: 6 to 18 (6, 10, 14, 18 ) Asymmetric crnil nd cudl surfces with 3-D convex shpe for optimized endplte contct. The improved instrumenttion enhnces ese of use compred with other systems in specific surgicl phses. Fig 3 Posterior relese tool. Posterior relese tool The posterior relese tool (Fig 3) is used s n lterntive to stndrd spreders (Fig 3). Fetures include: Allows for progressive nd controlled distrction nd posterior relese Brod tips void susidence of the instrument Posterior relese height is reproducile Chngele inserts for moiliztion prevent over-distrction. Fig 4 The evolution squid. Evolution Squid The evolution squid (Fig 4) is used s n lterntive to implnt holders (Fig 4): Distrcts nd inserts the implnt in one simple step without impction Offers multiple positioning options to recess implnt in disc spce Rils provided for sfe implnt guidnce during insertion Thin ldes prevent over-distrction during implnt insertion. Evolution tril rsps Evolution tril rsps (Fig 5) hve een specificlly designed to help smooth the end-pltes nd crete leeding to id with the inter-ody fusion. Ech tril rsp correltes with the finl desired implnt for insertion. Fig 5 Evolution tril rsp. AOTK SYSTEM INNOVATIONS 2015

39 SPINE 37 Cse provided y Pul Heini, Bern, Switzerlnd c Fig 6 c Preopertive stnding imges. Cse 1: 75-yer-old ptient A 75-yer-old femle ptient presented with postopertive ck pin. She hd een initilly operted on eight yers erlier with lminectomy nd fusion from L2 to L4. This proved to e successful for numer of yers until second opertion ws required for secondry ck pin nd left side leg pin. An extension of the decompression ws performed with stiliztion nd fusion from L1 to S1. The rtionle for this opertion ws unknown nd the surgery filed to improve her symptoms. The prolem to e ddressed ws the ptient s ck pin nd left side leg pin, inclusive of some wekness in her left foot. The pin ws present upon weight-ering, with pin scle of 9. Her discomfort remined t night. The ptient ws of slim uild nd ws in good generl helth. She presented with limp from her left hip nd the dorsiflexion of the left foot ws wek (M4). The preopertive stnding imge of the lumr spine reveled flt ck with no ovious degenertion of the djcent segment L1/L2 (Fig 6 ). The implnts seemed regulrly plced. After wide lminectomy, the spinl cnl ws open over the whole lumr spine, illustrted on the MRI scn (Fig 6c). A CT scn llowed more detiled ssessment (Fig 7). There ws n ovious nonunion t L5/S1, with loose screws in the scrum (red circle). Furthermore, there ws instility t L4/L5 s the interverterl disc presented with n importnt vcuum phenomenon (sterisk). Forminl stenosis t L5/S1 (not shown) seemed to e the reson ehind the persistent leg pin. c Fig 7 c CT scns. The tretment pln ws n nterior height restortion nd fusion of L5/S1 nd L4/L5. A posterior revision surgery ws not considered due to the wide decompression nd ovious scr formtion. For the correction of level L4/L5, n olique nterolterl pproch (OLIF) ws selected due to considerle clcifiction of the ort nd the ilic vessels. At the L5/S1 level, stright nterior pproch ws selected nd n dditionl plte fixtion (ATB) ws performed. At level L5/S1, lrge cge with n ngultion of 14 ws selected nd for L4/ L5, lrge cge with n ngultion of 10 ws plced. In order to perform fusion, the cges were ech filled with 6 mg of BMPII. From six months postopertively, leg discomfort decresed. Within n dditionl four months, pin disppered completely nd oth foot nd hip wekness recovered. The ck pin persists to certin extent ut is not impeding the ptient in her dily ctivities. The x-ry tken 10 months fter the nterior revision surgery reveled complete nd solid fusion on oth levels (Fig 8, sterisk). This is confirmed y the ppernce of dense one in the rdiolucent cge. c Fig 8 c Postopertive imges.

40 38 SPINE Cses provided y Khi Lm, London, UK Cse 2: 19-yer-old hockey plyer A 19-yer-old high-level college hockey plyer hd experienced 12 months of severe lower ck pin (LBP), nd ws unle to ply sport due to high disility nd pin (Fig 9). Nonopertive tretment with physiotherpy nd injections hd filed. Fig 9 Left nd right sided L5 lytic defect. The CT showed ilterl L5 spondylolysis with grde I spondylolisthesis (Fig 10). The ptient underwent miniml ccess L5/S1 nterior interody fusion with BMP followed y minimlly invsive Mtrix percutnous screw fixtion (Fig 11). Fig 10 Sgittl T2 MRI showing grde III L5/S1 disc degenertion over grde I L5/S1 lytic spondylolisthesis. Fig 11 Postopertive AP nd lterl x-rys. AOTK SYSTEM INNOVATIONS 2015

41 SPINE 39 Cse 3: 23-yer-old student A 23-yer-old femle college student hd experienced 3 yers of severe LBP with some right S1 scitic. She presented with high disility, filed nonopertive tretment, injections, nd pin killers. She ws unle to led norml life nd conduct ctivities of dily living. The sgittl nd xil T2-weighted MRI showed grde III disc degenertion with diffuse right-sided disc ulging (Fig 12). Fig 12 Sgittl nd xil T2-weighted MRIs. The postsurgery AP nd lterl imges show stnd-lone locked L5/S1 nterior fusion using Syncge Evolution with BMP-2 nd n Aegis locking plte (Fig 13). Fig 13 Postopertive AP nd lterl x-rys.

42 40 VETERINARY Erik Asimus, Brin Bele, Rndy Boudrieu, Loïc Déjrdin, Michel Kowleski VETERINARY Doule/Triple Pelvic Osteotomy (DPO/TPO) Plte The Doule/Triple Pelvic Osteotomy (DPO/TPO) plte (Fig 1) is indicted for treting coxofemorl joint instility nd suluxtion in immture dogs prior to the onset of osteorthritis. The DPO/TPO plte is 3.2 mm thick nd ville in right nd left versions with ngultions of 20, 25, nd 30 etween the plte surfces to fcilitte the rottionl osteotomy of the cetulr one segment. Fig 1 llustrting DPO procedure with veterinry DPO/TPO plte on cnine pelvis. Bckground At lest 3.5% of the glol dog popultion suffers from hip dysplsi [1] nd this cn rech 50% in lrger reeds [2]. Rottionl pelvic osteotomies constitute prophylctic surgicl interventions intended to decrese norml hip joint lxity, normlize rticulr stresses, nd improve hip joint congruity. Currently, the DPO nd TPO re the most populr corrective procedures. However, despite technique modifictions nd the development of new pltes, complictions such s implnt loosening, reduction of the pelvic inlet dimeter, over- or under-rottion of the cetulr rim, nd delyed heling of the osteotomies cn occur. Plte design The recently lunched DPO/TPO plte offers sustntil improvements to existing one fixtion pltes to overcome these complictions (Fig 2). Fetures of the plte include: Screw trjectories designed to optimize screw purchse into the reltively soft one Antomiclly contoured to mtch the ilil shft nd to llow clernce for cetulr flre nd the tuerosity t the origin of the rectus femoris muscle Plte design includes two distinct screw-hole technologies to ccommodte ll plting modlities (stcked comi holes nd coxil comi-hole) Incorportion of locking technology permits fixed-ngle device to increse construct strength. References 1 LFond E, Breur GJ, Austin CC. Breed susceptiility for developmentl orthopedic diseses in dogs. J Am Anim Hosp Assoc Sep Oct; 38(5): Todhunter RJ, Mteescu R, Lust G, et l. Quntittive trit loci for hip dysplsi in cross-reed cnine pedigree. Mmm Genome Sep; 16(9): AOTK SYSTEM INNOVATIONS 2015

43 VETERINARY 41 Fig 2 Side view of the DPO/TPO plte showing the optimized screw ngultions. Stcked Comi holes ccept locking or cortex screws K-wires holes for temporry stiliztion (1.6 mm) Cudl Crnil Aility to perform either DPO or TPO with the sme plte Precontoured shpe for ntomic fit Comi hole ccepts locking or cortex screws Fig 2 Top view of the DPO/TPO plte demonstrting its fetures. Cse provided y Brin Bele, Houston, USA Fig 3 A distrction x-ry view reveled ilterl hip joint lxity. Cse 1: Lrdor retriever puppy A 5½-month-old spyed femle lrdor retriever puppy weighing 22.0 kg presented with ilterl hind lim wekness nd unny-hopping git in the hind lims. Physicl exmintion reveled ilterl hip instility (positive Ortolni sign) nd mild pin on full extension of the hips. Slight crepitus ws plpted in the left hip. The glutel muscles ppered to hve mild trophy. The neurologicl exm ws norml. X-ry exmintions reveled ilterl hip suluxtion nd distrction index of 0.5 of the right hip nd 0.7 of the left hip (Fig 3). No evidence of osteorthritis ws oserved.

44 42 VETERINARY Fig 4 Postopertive x-rys. A DPO ws performed on the right hip using 25 DPO/TPO plte. Excellent femorl hed cpture (reduction) ws chieved. Fig 5 Postopertive x-rys t 7 weeks. Fig 6 Postopertive x-rys t 6 months following surgery. A dignosis of juvenile hip dysplsi ws mde. The right hip ws considered n cceptle cndidte for doule pelvic osteotomy (DPO; note tht in 5½-month-old dog, n osteotomy of the puis (s performed in TPO) is not necessry due to the ony complince t this young ge). The left hip conformtion ws considered too norml for corrective osteotomy nd ws not treted. The owner ws counseled tht totl hip replcement (THR) my e needed in the future on the left hip. Angles of suluxtion (10 ) nd reduction (30 ) of the right hip were mesured under nesthesi nd the ptient ws plced in dorsl recumency. A 7 mm portion of the right puic ody ws excised. The ptient ws repositioned into lterl recumency. A right ilil osteotomy ws mde immeditely cudl to the scrum. A 25 DPO/TPO plte ws ttched to the cudl ilil one segment using locking 3.5 mm screws in the three stcked comi holes. The cudl cetulr segment ws rotted lterlly until the crnil spect of the plte ws in contct with the lterl spect of the crnil ilil segment. The osteotomy site ws compressed, nd the plte ws secured to the crnil ilil one segment using 3.5 mm corticl screw in the LCP comi hole in the crnil side of the plte. Three dditionl 3.5 mm locking screws were plced in the remining stcked comi holes in the crnil segment of the plte. Postopertive x-rys reveled reduction in suluxtion with cpture of the femorl hed in the right coxofemorl joint (Fig 4). Plption of the hip reveled good stility of the right hip. Activity ws restricted to lesh wlk only for 6 weeks postopertively. The x-rys t 7 weeks following surgery reveled heling of the ilil osteotomy, stle implnts, nd excellent coxofemorl conformtion nd stility (Fig 5). The x-ry exmintion t 6 months postsurgery reveled stle implnts, excellent coxofemorl conformtion, nd no evidence of osteorthritis of the right hip. The left cetulum ws mildly shllow nd mild suluxtion of the femorl hed ws present t follow-up exmintion (Fig 6). Erly osteophytosis in the region of the left femorl neck ws evident. The dog ws using the right hind leg normlly nd ws showing no signs of instility or pin of the right hip. Mild instility nd pin of the left hip ws present on plption. The dog s left hip ws treted with joint supplement nd NSAIDs s needed. Future THR will e performed if clinicl signs no longer respond to medicl tretment. AOTK SYSTEM INNOVATIONS 2015

45 VETERINARY 43 Cse provided y Erik Asimus, Toulouse, Frnce Fig 7 A distrction x-ry reveled ilterl hip joint lxity. Fig 8 Femorl hed coverge is demonstrted y the dorsl cetulr rim view. Cse 2: Boxer puppy A 4½-month-old femle oxer puppy weighing 15.0 kg presented with ilterl hind lim wekness nd reluctnce to wlk. Physicl exmintion reveled ilterl hip instility (positive Ortolni sign) nd severe pin on full extension of the hips. The neurologicl exm ws norml. The x-rys reveled ilterl hip suluxtion nd distrction index of 0.65 of the right hip nd 0.6 of the left hip (Fig 7). Very mild osteorthritis ws seen nd femorl hed coverge y the dorsl cetulr rim ws good (Fig 8). Angles of suluxtion (10 R nd 20 L) nd reduction (30 R nd 40 L) of the hips were mesured under nesthesi. A dignosis of juvenile hip dysplsi ws mde. Both hips were considered s cndidte for doule pelvic osteotomy (DPO). Considering the difficulty to limit the ctivity of this ctive puppy, simultneous ilterl procedure ws not performed. The left hip DPO ws performed first, followed y the right hip 4 weeks lter. For ech surgicl procedure, the ptient ws plced in dorsl recumency to enle the puic ostectomy. The ptient ws repositioned in lterl recumency to perform the DPO. A left ilil osteotomy ws performed cudl to the scrum. A 25 DPO/TPO plte ws ttched to the cudl ilil segment using locking 3.5 mm screws in the three stcked comi holes. The cudl cetulr segment ws rotted lterlly until the crnil spect of the plte ws in contct with the lterl spect of the crnil ilil segment. The osteotomy site ws compressed nd the plte ws secured to the crnil ilil one segment using 3.5 mm corticl screw in the LCP comi hole in the crnil side of the plte. Three dditionl 3.5 mm locking screws were plced in the remining stcked comi holes in the crnil segment of the plte (Fig 9). Fig 9 1-month postopertive x-rys of the DPO performed first on the left hip using 25 DPO/TPO plte. Excellent femorl hed cpture nd stility were chieved. Activity ws restricted to lesh wlks for 6 weeks postopertively. The x-ry exmintion 1 month fter ech surgery reveled prtil heling of the ilil osteotomy nd stle implnts. Postopertive x-rys t 6 months fter oth surgicl procedures reveled complete heling of the ilil osteotomies, stle implnts, nd excellent coxofemorl conformtion, with no suluxtion of the femerol hed. Mild osteorthritis ws oserved, however. At oth the 4 nd 6 month evlution, the dog ws using oth hind lims without ny evidence of lmeness nd ws showing no signs of instility or pin of either hip (Fig 10). Fig 10 X-rys t 4 () nd 6 months ().

46 44 AOTK MEET THE EXPERTS AOTK MEET THE EXPERTS Meet the Experts progrm History nd recent events The AO Dvos Courses Meet the Experts sessions strted in 2011 s n informl wy of introducing AOTK pproved product innovtion to the glol orthopedic community. This product introduction, inclusive of pproch nd technique, hs een lrgely performed y surgeons involved in the product development process nd hs ecome one of the most importnt ctivities orgnized y AOTK ech yer. Successful chnge of loction As result of oth the populrity of Meet the Experts nd the need to find quiet environment, 2014 witnessed chnge of venue within the Congress Centre for these sessions. Cfé Chmonix will remin the chosen spce for 2015 cross oth weeks. Meet the Experts sessions 2014 During AO Dvos Courses 2014, Theddy Slongo nd Spence Reid, oth clinicl memers of the Externl Fixtion Expert Group, presented the ring fixtor s tool for enling distrction in long ones. The Distrction Osteogenesis (DO) ws shown to e verstile nd modulr ring system tht llowed multiple frme options nd offered vile lterntives for deformity corrections nd frcture mngement. The presenters then successfully demonstrted how to utilize the DO frme for lim lengthening nd singulr ngulr correction. Michel Bluth nd Christopher Finkemeier, memers of the Intrmedullry Niling Expert Group, demonstrted nd explined the fetures of the new TFN-Advnced Proximl Femorl Niling system (TFNA) (Fig 1) nd demonstrted the importnce of iming guides for the insertion of oth the nil nd the femorl hed fixtion element. More informtion on the TFNA is found in the led rticle of this edition of TK Innovtions. Fig 1 Michel Bluth nd Christopher Finkemeier demonstrte the TFNA. AOTK SYSTEM INNOVATIONS 2015

47 AOTK MEET THE EXPERTS 45 Andy Snds nd Michel Cstro from the Foot nd Ankle Expert Group gve n overview of the tretment options ville with the new Vrile Angle Midfoot/Hindfoot system. The new system hs the cpcity to offer vrile ngle fixtion in much the sme wy s the forefoot/ midfoot system previously developed y the Foot nd Ankle Expert Group. However, in comprison to older hindfoot plte options, the new VA clcnel pltes re now ville in vriety of shpes to ccommodte the multiple fixtion strtegies required for different frcture ptterns. Michel Rschke delivered highly informtive session outlining the properties of iomterils such s ntiiotic PMMA nd ntiioticcoted implnts nd their use in the prevention of implnt-relted infections. The discussion emphsized oth the importnce of prophylxis using oth systemic nd locl ntiiotics nd the vlue of using iomterils to erdicte pthogens nd reconstruct one in cses of estlished one infection. Stefno Fusetti led n interesting nd interctive session descriing the fetures of the MtrixWAVE plte (Fig 2), newly pproved device for mxillomndiulr fixtion (MMF). Indictions for use of the plte were outlined, s were the dvntges offered y the new device. Audience memers were le to oserve the MtrixWAVE plte eing pplied to model skull nd the requisite surgicl instruments nd techniques. In 2014, AOVET prticipted in the Meet the Experts progrm for the first time, with Brin Bele nd Mike Kowleski (Fig 3) demonstrting the Doule/Triple Pelvic Osteotomy Pltes for treting coxofemorl joint instility nd suluxtion in immture dogs. Fig 2 Stefno Fusetti demonstrtes the new MtrixWAVE plte. Fig 3 Brin Bele nd Mike Kowleski demonstrte the ltest VET pltes.

48 46 AOTK MEET THE EXPERTS Roger Härtl gve comprehensive overview of the cutting-edge nvigtion technology ville for spine surgery (Fig 4) including Viper nvigted instruments nd the 2D Fluoro Nvigtion system. A leder in the field of nvigtion, Roger emphsized reference rry fixtion, impertive for the ttinment of ccurcy in nvigted surgery, nd screw model visuliztion, which offered the surgeon choice etween full nd prtil screw visuliztion (Fig 5). More informtion on computer ssisted surgery cn e found in the Minimlly Invsive 2D rticle in the Spine section of this edition. Neurosurgeons Christin Mtul, Rocco Armond, nd Stephen Lewis concluded the progrm delivering highly engging wecst descriing innovtions in durl repir (Fig 6). They demonstrted the use of SYNTHECEL, synthetic durl implnt sed on iosynthesized cellulose technology, nd Durform, nother synthetic durl sustitute. This session ws rodcst live to AO memers round the world nd included immedite interction from the internet udience. Fig 4 Leding spine surgeon Roger Härtl demonstrtes the ltest nvigtion systems. Fig 5 Nvigtion system used in spine surgery. Fig 6 Christin Mtul, Rocco Armond, nd Stephen Lewis outline the fetures of the ltest synthetic durl implnts. AOTK SYSTEM INNOVATIONS 2015

49 NEWS FROM ARI 47 Krl Stoffel, Christoph Sommer, Ivn Zderic, Ursul Eerli, Dvid Mueller, Mrtin Oswld, Boyko Gueorguiev NEWS FROM ARI Biomechnicl Evlution of Femorl Neck Frcture Fixtion with the new Femorl Neck System: Comprison with DHS-Blde, DHS with Antirottion Screw, nd three Cnnulted Screws Clinicl Bckground The Dynmic Hip Screw (DHS) is considered the gold stndrd for the fixtion of unstle sucpitl or trnscervicl femorl neck frctures type AO/OTA 31 B. However, the prominence of the implnt cn e pinful. As n lterntive, three Cnnulted Screws (3CS) my e used, however, the fixtion might not provide enough stility in cses of displced frctures. The im of this project ws to evlute the iomechnicl performnce of the new less-invsive implnt, the Femorl Neck System [1] (FNS) (Fig 1) nd compre it to estlished fixtion methods using DHS Screw, DHS Blde, nd 3CS in humn cdveric model. Fig 1 The new Femorl Neck System for femorl neck frcture fixtion. Mterils/methods Twenty pirs of fresh-frozen ntomicl specimen femor were instrumented with either DHS Screw, DHS Blde, FNS, or 3CS. A reduced unstle femorl neck frcture 70 Puwels III, AO/OTA 31 B2.3 ws set stndrdized with 30 distl nd 15 posterior wedges in respect to the frcture plne using custom sw-guide. Biomechnicl ssessment ws performed with the specimens mounted on mteril testing F T F H Fig 2 Biomechnicl testing. A free ody digrm of the femur. F T ) Aductor muscle force cting on the greter trochnter. F H ) Hip contct force. Test setup with left femur specimen mounted for iomechnicl testing nd instrumented with FNS. 1) Lod cell. 2) Liner guide ssuring free centre of the femorl hed rottion. 3) PMMA shell simulting the cetulum. 4) Brcing ttchment to simulte the iliotiil nd of the ductor muscles. 5) Crdn joint preventing displcement nd xil rottion of the specimen. 6 c) Three retro-reflective mrker sets ttched to the femorl hed, shft, nd implnt for opticl motion trcking.

50 48 NEWS FROM ARI mchine in 16 femorl shft lterl ngultion (Fig 2). Strting t 500 N, cyclic compression loding long the trnsducer xis ws pplied to the femur, with incresing pek force t rte of 0.1 N/cycle until construct filure. Mchine dt ws used to clculte the xil construct stiffness immeditely fter test strt. Reltive interfrgmentry movements long the femorl shft nd neck xis were evluted with opticl motion trcking (leg/femorl neck shortening). Sttisticl nlysis ws performed t level of significnce set to Results The highest xil stiffness ws oserved, on verge, using the FNS, followed y the DHS Screw, DHS Blde, nd 3CS, with no significnt differences etween the implnt systems. Cycles until 15 mm leg shortening were similr for DHS Screw, DHS Blde, nd FNS, nd significntly higher in comprison to 3CS (p<0.001). Similrly, cycles until 15 mm femorl neck shortening were comprle etween DHS Screw, DHS Blde, nd FNS, nd significntly higher compred to 3CS (p<0.001). The results re summrized in Tle 1. Conclusion The iomechnicl performnce of the FNS is comprle to either of the DHS implnts, nd s with them, significntly etter thn 3CS in terms of resistnce to leg nd neck shortening under cyclic loding. In ddition, FNS is potentilly less invsive thn DHS, which mkes it competitive product for unstle femorl neck frcture tretment. Note 1 Regultory pprovl for the Femorl Neck System is pending. DHS Screw DHS Blde FNS 3CS Axil stiffness [N/mm] ± ± ± ± 47.2 Cycles until 15 mm leg shortening 20,542 ± 2,488 19,161 ± 1,264 17,372 ± 947 7,293 ± 850 Cycles until 15 mm femorl neck shortening 20,846 ± 2,446 18,974 ± 1,344 18,171 ± 818 8,039 ± 838 Tle 1 Prmeters of interest for the implnt systems (men ± SEM). AOTK SYSTEM INNOVATIONS 2015

51 NEWS FROM ARI 49 Mnuel Ernst, Dnkwrd Höntzsch, Ronld Schwyn, Stefn Döele, Mrkus Windolf AO Frcture Monitor: sensory implnt tht trnsmits one repir nd heling informtion Implnts dopt the stilizing function of one for the durtion of the frcture, nd the loding on the implnt chnges throughout the course of one repir. Recording implnt loding is n indirect mesurement of frcture consolidtion nd cn contriute to n improved ssessment of one heling. The AO Reserch Institute (ARI) hs developed the AO Frcture Monitor, which is system cple of continuously mesuring this lod nd trnsmitting the informtion to the physicin [1]. The dt ssists the surgeon with decision mking on corrective ctions such s dpted ftercre, or reopertion t n erly stge. The dt cn lso help improve implnt design to ensure proper one heling. Fig 1 Clinicl ppliction of the AO Frcture Monitor ttched to n externl fixtor side-r (red circle). Fig 2 Averge externl fixtor lod in two ptients over period of two months. The drop of the curve over time in ptient A indictes the onset of frcture heling. The AO Frcture Monitor consists of dt logger unit with n interfce for wireless communiction using computer or smrtphone, nd we pltform for collection, dministrtion, nd visuliztion of ptient dt. The logger itself comprises sensor nd n electronic unit for on-ord processing of the dt into meningful prmeters to ssess heling progression. In contrst to lterntive pproches, the AO Frcture Monitor cn exmine the course of heling utonomously nd continuously over long periods of time. This llows for the recording of other importnt io-dt, such s ptient ctivity profiles. In n initil phse, version of the AO Frcture Monitor hs een developed for use with externl fixtion, mesuring the deflection of fixtor sider under functionl loding (Fig 1). This helps determine the fesiility of the technology, s mesurements cn e performed noninvsively nd t miniml risk to the ptient. A clinicl tril is currently eing conducted y AOCID in ptients with externl fixtor tretment of tiil frctures. Detecting the onset of heling illustrtion As n exmple, the heling curves of two ptients re compred (Fig 2). Ptient A shows n onset of heling (lue curve), indicted y mild decline of the verge loding mplitude over time, while ptient B shows no signs of frcture heling during the monitoring period (red curve). There cn e multiple resons for the sence of heling, however, distinct difference in weight-ering ecomes ovious. Ptient A lods on verge with kg, wheres ptient B only weight-ers t kg (Fig 2). The sitution is further visulized y ctivity histogrms lso delivered y the frcture monitor (Fig 3).

52 50 NEWS FROM ARI Steps tken y the ptient re counted nd orgnized into three distinct ins ccording to loding intensity. While the overll ctivity of oth ptients is more or less comprle (in verge steps/h), the intensity distriution is quite different. While roughly 70% of ll recorded steps of ptient B re in the rnge of kg, ptient A loders only 20 30% in this rnge nd pproximtely 40% t ove 50 kg. The onset of heling in ptient A is indicted y fde-out of the >50 kg loding events over time (Fig 3). Consecutive fde-out of the other loding ins is nticipted with ongoing heling. Heling dignostics solely sed on x-rys cn e difficult in this cse (Fig 4). This exmple illustrtes the cpilities of the system nd stresses the importnce of iofeedck for controlling frcture heling. The preliminry results re encourging, nd demonstrte tht the system is cple of detecting heling even in cses displying history of delyed-union, infection, nd pseudorthrosis. As result, the system could potentilly offer n erly wrning of poor heling or nonunion. A version for ppliction with internl fixtion is currently under development nd will enter the preclinicl test phse soon. References 1 Windolf M, Ernst M, Schwyn R, et l. A iofeedck system for continuous monitoring of one heling. In: Proceedings of the Interntionl Conference on Biomedicl Electronics nd Devices. 2014: DOI: / c d Fig 3 d Asolute (, c) nd reltive (, d) ctivity dt of the two ptients, sorted ccording to loding intensity. The onset of heling in ptient A ecomes pprent y fde-out of >500N loding events over time (). In contrst, no signs of heling re detected in ptient B (d). Fig 4 Mediolterl x-rys of ptients A nd B t the end of the monitoring period. AOTK SYSTEM INNOVATIONS 2015

53 NEWS FROM AO EDUCATION INSTITUTE 51 NEWS FROM AO EDUCATION INSTITUTE AOTrum STRT (Surgicl Trining nd Assessment for Residents) The AO Foundtion s very own AOTrum STRT (Surgicl Trining nd Assessment for Residents) (Fig 1) is n wrd-winning interctive online lerning hu for orthopedic trum residents. Lerning ctivities re sed on typicl ptient prolems, mking it esier for residents to directly pply wht they lern into their dily prctice. It invites lerners to e proctive in identifying knowledge gps nd offers resources to ddress them. Content is grded into vrious levels of complexity nd is ligned with the AOTrum Residents Eduction Progrm. Fig 1 AOTrum STRT engge, ssess, rowse. The min fetures of AOTrum STRT include: Interctive cse discussions, which ssist lerning sed on common ptient prolems Self-ssessment questions to ssist with the identifiction of knowledge gps, where lerners cn test themselves with multiplechoice questions (from sic to complex) receiving immedite feedck Access to existing AO lerning mterils, which re lelled ccording to complexity, nd inclusive of n extensive lirry of eductionl resources including videos, weinrs, wecsts, elerning modules, pps, nd AO Surgery Reference. Fig 2 W el Th nd Kodi Kojim, AOTrum STRT Executive Editors. Creted y surgeons for surgeons The content uthors re experienced fculty from ech of the AOTrum regions nd work in tems to chieve nd mintin n interntionl focus (Figs 2 6). These uthors re involved in the teching nd trining of residents on dily sis, nd re committed to providing content tht is current, interesting, nd evidence sed. Fig 3 Joyce Koh (from Singpore), Chnkrn Phornphutkul (from Thilnd), nd John Mukhopdhy (from Indi), uthors of the humerl shft module, with AOTrum STRT Project Mnger Koke Aee (2nd from left), show the diversity of ckgrounds tht re rought together in developing the progrm.

54 52 NEWS FROM AO EDUCATION INSTITUTE Interntionl recognition nd wrds Since its lunch in 2014, AOTrum STRT hs chieved interntionl recognition nd climed rod rnge of prestigious medicl eduction wrds. These include Pltinum wrd from the ehelthcre Ledership Awrds, Silver in the Physicin/Clinicin Portl Wesite ctegory from the 2014 We Helth Awrds, nd n outstnding chievement wrd t the 2014 Interctive Medi Awrds. This success continued this yer with two more outstnding chievement wrds t the 2015 Interctive Medi Awrds. Fig 4 Greg Bin from Austrli presents distl rdius module. AOTrum STRT pplies proven eductionl strtegies to support orthopedic trum residents, nd is committed to providing vlule feedck nd fst ccess to relevnt informtion. As result, we elieve tht this progrm goes long wy to helping residents improve ptient cre in their community. You cn find more out AOTrum STRT t or contct Project Mnger Koke Aee t koke.ee@ofoundtion.org for more informtion. Fig 5 Michel Möller from Sweden presents periprostetic frcture to test residents knowledge of ptient mngement. North Americ 250 Europe 1738 Asi Pcific 695 Fig 6 Approximtely 4200 residents, junior prctitioners, nd even senior prctitioners from ll over the world hve registered for AOTrum STRT (s t August 2015) Ltin Americ Middle Est 500 AOTK SYSTEM INNOVATIONS 2015

55 NEWS FROM AO EDUCATION INSTITUTE 53 New AO Pulictions Frctures of the Pelvis nd Acetulum In June 2015, the ltest edition of AO Pst President Mrvin Tile s, Frctures of the Pelvis nd Acetulum Principles nd Methods of Mngement, ws lunched in Ls Vegs. This fourth edition (Fig 1) is now two-volume set sed on the renowned AO principles of opertive mngement of frctures in this re. Fig 1 The two-ook set of Frctures of the Pelvis nd Acetulum Principles nd Methods of Mngement-Fourth Edition. The ook covers in gret detil the mngement of cute pelvic nd cetulr frctures, definitive tretment, nd extensive discussion nd nlysis on expected outcomes. Including dozens of highly detiled cses nd hundreds of imges, this new edition of n existing gold stndrd puliction is idel for ll surgeons interested nd involved in pelvic nd cetulr surgery. Periprosthetic Frcture Mngement With n ever ging popultion comes growing demnd for joint implnt surgery. However, this growth hs resulted in n increse in the numer of ptients with implnt relted frctures. Fig 2 Periprosthetic Frcture Mngement. Bringing together the ltest glol knowledge on periprosthetic frctures, Periprosthetic Frcture Mngement (Fig 2) exmines the pproches, tretment options, nd surgicl pitflls involved with these types of frctures, nd provides the reder with n overview of the typicl prolems, nd vriety of interesting nd complex cses, in ech ntomicl re. This puliction lso introduces the new Unified Clssifiction System on Periprosthetic Frctures, idel for helping to recognize nd descrie these often prolemtic frcture situtions. Csts, Splints, nd Nonopertive Tretment Csts, Splints, nd Support Bndges Nonopertive Tretment nd Periopertive Protection (Fig 3) covers the principles of csting nd one heling, the unique fetures of cst mterils, clssifictions nd guidelines for nonopertive tretment, nd step-y-step descriptions of dozens of individul cst, splint, orthosis, nd ndging procedures. Fig 3 Csts, Splints, nd Support Bndges Nonopertive Tretment nd Periopertive Protection. The puliction lso includes ccess to 55 cst, splint, nd ndging demonstrtion videos, covering the upper nd lower extremities nd the spine. This incredily comprehensive text on nonopertive techniques will e of interest to wide rnge of medicl professionls, residents in trining, nd ORP. For further informtion on ny of the mterils nd pulictions produced y AO Pulishing, visit the pulishing section of the AO Foundtion wesite.

56 54 NEWS FROM AOCID NEWS FROM AOCID Clinicl trils updte AO Clinicl Investigtion nd Documenttion (AOCID) is the min AOTK prtner for the conduct of clinicl trils. This yer, AOCID is involved in totl of 76 clinicl studies nd registries, of which more thn one-third re sponsored or cosponsored y AOTK. In this issue of TK Innovtions, AOCID provides n outline of the PFNA ugmenttion study nd the Trolley clinicl investigtion. There is lso focus on smrt implnts through short description of the SmrtFix focussed registry. Finlly, we shre some tips on elements tht sites need to hve to successfully contriute to clinicl investigtion. More informtion on AOCID s work cn e found t Fig 1 X-ry imge of the Proximl Femorl Nil Antirottion (PFNA) plus ugmenttion. Comprison of Proximl Femorl Nil Antirottion (PFNA) vs PFNA ugmenttion for the tretment of closed unstle trochnteric frctures: rndomized-controlled tril The purpose of this study is to evlute whether ptients with trochnteric frctures treted with Proximl Femorl Nil Antirottion (PFNA) plus ugmenttion (Fig 1) cn e etter moilized thn ptients without ugmenttion. In order to void the pin cused y reltive movement etween implnt nd one, surgicl techniques nd devices enling ugmenttion of the femorl hed hve recently een developed. Biomechnicl studies hve illustrted tht ugmenttion leds to etter xil stility nd incresed pull-out strength. In clinicl prctice, this might fcilitte erly moiliztion nd full weight-ering with less pin. Using the TUG test (Timed Up nd Go), the study will lso mesure whether ptients with n ugmented PFNA re le to wlk fster thn nonugmented ptients. The study evolved from the Intrmedullry Niling Expert Group (INEG), nd the current estimted ptient enrolment is 251. The study strted in Ferury 2012 nd is predicted for completion y the end of Nine clinics from six countries hve een prticipting. AOTK SYSTEM INNOVATIONS 2015

57 NEWS FROM AOCID 55 Evlution of growth guiding construct vs stndrd dul growing rods nd VEPTR for the tretment of erly onset scoliosis ptients: prospective multicenter cohort study with mtched historicl control (the Trolley study) The primry chllenge when mnging erly onset scoliosis (curve deformity efore the ge of 10) is to prevent curve progression while mintining growth of the spine. Current tretment options require repetitive interventions s oth the spine nd child grow. This study will compre two techniques of growth modultion: stndrd dul growing rods versus the new Luqué Trolley screws. c Fig 2 Trolley technique instrumenttion. Four-rod technique. Two-rod tehnique with picl fusion. c Two-rod technique with distl fusion. One third of ptients will e recruited in designted investigtion sites using the Trolley system (Fig 2). For every ptient receiving the Trolley implnt, 1-2 comprtive mtched pirs will e tken from the Chest Wll nd Spine Deformity Study Group (CWSDSG) nd the Growing Spine Study Group (GSSG). The study hypothesis is tht ptients treted with the Trolley system will undergo fewer reopertions fter 3 yers of follow-up thn ptients included in the comprison group. Five clinics will prtke in this investigtion, which strted in Septemer Clinicl dt collection with novel iofeedck technology for continuous monitoring of one heling (the SmrtFix focused registry) In this tril, novel dt logger device (AO Frcture Monitor), developed t the AO Reserch Institute in Dvos, is used to continuously mesure the decline in fixtion hrdwre deflection under physiologicl loding s n indirect indictor for heling progress. Prmeters otined from the dt logger device crry the potentil to significntly improve the ssessment of frcture heling in the future. Meningful interprettion of mesurements requires set of clinicl reference dt. Twenty ptients tht received n AO lrge externl fixtor for tiil frcture will e equipped with dt logger device (AO Frcture Monitor), ttched postopertively. The device will continuously mesure deformtion on the fixtor frme due to weight ering for up to 4 months y mens of strin guge. Severl prmeters re clculted from the recorded chnge in the strin signl nd the dt collected t follow-up visits y wireless dt trnsfer. Together with dditionl vriles such s tretment detils, frcture heling, nd pin reported y the ptient, the collected dt will e used to uild up dtse. Dt from the AO Frcture Monitor will e correlted with ptient dt to investigte the cpility of the device to trck the course of frcture heling.

58 56 NEWS FROM AOCID The SmrtFix study egn in Jnury 2015 nd is expected to continue until Mrch A totl of 20 ptients re plnned to e recruited for this focused registry. You cn red more out the AO Frcture Monitor system in the News from ARI section (pge 49) of this issue. Fig 3 Reviewing the results in n AOCID conducted study. Do you think your clinic hs got wht it tkes to ecome study site? Possessing mny yers of experience in the conduct of clinicl trils, AOCID highlights the following elements to e mrkers for success in clinicl reserch (Fig 3): Dedicted Principl Investigtor (PI) Avilility of study coordintor or Clinicl Trils Unit (CTU) Relistic ptient recruitment predictions Avilility of implnts nd sets Legl sitution conducive to the conduct of clinicl trils Continuity, in terms of personnel etc Proctive recruitment (ie, no overrelince on residents to recruit) Approprite source dt collection processes nd tools Frequent nd open communiction Motivted clinicl reserch tem memers. How does your clinic mesure up to these criteri? If you would like to know more out wht is expected of centers in clinicl tril, you cn view n exmple site selection questionnire from the TMT Fusion Plte study in the Resources section of the AOCID wesite: AOTK SYSTEM INNOVATIONS 2015

59 NEWS FROM AOTK 57 NEWS FROM AOTK AOTK Experts Symposi Evolution nd purpose Product feedck from expert clinicins worldwide is primry focus of the AOTK pproch to reserch nd development nd qulity ssurnce. AOTK regulrly holds n Experts Symposium, inviting AO memers to come together to evlute AOTK pproved product performnce nd to shre experiences, of enefit oth cliniclly nd in the development of eductionl mterils. Since its first Experts Symposium held in 2000, AOTK hs regulrly orgnized such surgeon exchnges cross the vrious AO regions nd elieves strongly tht the vlue of this expert collortion leds to continul improvement to oth product development nd ptient cre. Fig 1 Prticipnts of the 9th AOTK Experts Symposium in Innsruck, Austri. Fig 2 Tim Pohlemnn explins the function of smrt implnts for continuously monitoring frcture heling. 9th Europen AOTK Experts Symposium, Innsruck, Austri, Septemer 2014 Thirty nine expert surgeons from nine Europen countries ttended the symposium in Austri (Fig 1), orgnized in coopertion with AOTrum, with prticipnts presenting their most chllenging clinicl cses in the res of ugmenttion in the humerus nd femur, fixtion of the qudrilterl surfce, tii hed frcture fixtion, periprosthetic frcture mngement, ptell frcture tretment, nd remer/ irrigtor/spirtor procedures. There ws cler consensus tht the AO tension nd wiring of ptell frctures ws no longer the Gold Stndrd nd tht teching mterils hd to e updted. Fixtion with cnnulted screws nd tension nd s well s plte ppliction seemed to constitute the current trend for ptell fixtion. The periprosthetic frcture mngement session illustrted clinicl situtions tht re insufficiently ddressed with current hrdwre. In response, AOTK hs now formed Periprosthetic Frcture Tsk Force, which will work in collortion with DepuySynthes on new implnt development. Further discussions included the remer/ irrigtor/spirtor (RIA) procedures nd the importnce of controlling the remer hed intropertively in nterior nd lterl views. The event included two keynote lectures, firstly y Prof Tim Pohlemnn, who presented his views on the future potentil of Smrt Implnts to ssess one heling (Fig 2), while Prof Michel Wgner pssiontely reported on his experiences to improve trum ptient cre in Irq. Book wrds were presented for the est cse presenttions t ech of the two dys of the symposium, with Dr Crlier (from Belgium) receiving his prize for his tretment strtegy on reconstructing the qudrilterl surfce, nd Dr Sur Snchez (from Spin) for his pproch to the tretment of complex ptell frctures with clcneus plte.

60 58 NEWS FROM AOTK 2nd Ltin Americ AOTK Experts Symposium, Lim, Peru, Mrch 2015 Thirty three expert surgeons from nine Ltin Americn countries ttended the symposium in Lim (Fig 3), which ws chired y Dr Jun Gerstner Grces (medicl memer of the AOTK Foot nd Ankle Expert Group). After introductory lectures from Prof Jime Quintero nd Dr Rodrigo Pesntez (Fig 4), the prticipnts split into rekout sessions to discuss clinicl chllenges nd needs in the res of foot nd nkle, hnd nd upper extremity, hip nd knee, pelvis, IM niling, nd externl fixtion. Fig 3 Prticipnts of the 2nd Ltin Americ AOTK Experts Symposium in Lim, Peru. The groups from ech rekout session prepred summry presenttion with specil emphsis on new product development nd tretment ides to improve ptient cre. These presenttions were susequently shred with ll prticipnts in generl ssemly to llow in-depth discussion of the suggested ides. The discussions were very lively nd demonstrted the enthusism nd dediction of the prticipnts to crete etter tretment solutions. Fig 4 Dr Rodrigo Pesntez, chir of the hip nd knee rekout session, expressed verlly (nd in his clothing) the importnce of eing cretive in reltion to product development. The prticipnts from the hip nd knee rekout session suggested the development of modulr lde plte to fcilitte surgicl procedures. Furthermore, concept for n iming device designed to plce guide wires more ccurtely received wide support from the udience. In hnd nd upper extremity, modulr plte solution ws discussed for complex distl rdius frctures. Interestingly, implnt modulrity ws mentioned on severl occsions during the symposium, which illustrtes the importnce of providing surgeons with modulr, esy-touse implnt toolox to ddress vriety of frcture ptterns in n optiml mnner. In the foot nd nkle session, new implnt design for tiio-tlo-clcnel rthrodesis ws enthusisticlly evolved through lively dete. The pelvic group discussed new tretment strtegies to improve the fixtion of the qudrilterl surfce. Trgeting devices to fcilitte nil interlocking s well s tips nd tricks for niling proximl tiil frctures were discussed in the IM niling rekout session. Finlly, the externl fixtion discussion emphsized the potentil enefits of universl distrctor set in the fcilittion of reduction techniques cross vriety of ntomicl regions. AOTK SYSTEM INNOVATIONS 2015

61 AOTK AWARDS 59 Tim Pohlemnn AOTK AWARDS AOTK Innovtion Prize 2014 The prestigious AOTK Innovtion Prize is wrded in recognition of continued improvement to ptient cre. In 2014, it ws wrded to Prof Michel Rschke nd Prof Gerhrd Schmidmier (Fig 1) for their contriution to the development of the PROtect Niling fmily. The ntiiotic coted Expert Tiil Nil PROtect (ETN PROtect) ws developed s solution to implnt surfce cteril coloniztion in cses with n incresed risk of locl one infection. It represents one of the first mjor ttempts to ddress the issue of infection in frctures nd will hopefully inspire further development in the future. Profs Rschke nd Schmidmier receive their certifictes t the TK Chirmn s meeting in Dvos. From left to right, Dniel Buchinder (AOTK CMF Chirmn), Michel Rschke, Gerhrd Schmidmier, Tim Pohlemnn (AOTK Trum Chirmn), nd Roert McGuire (former AOTK Spine Chirmn).

62 60 PORTRAIT Christoph Sommer PORTRAIT: KARL STOFFEL Krl Stoffel is specilist orthopedic trum surgeon whose enjoyment of chllenge is evident oth professionlly nd personlly. Born in 1968 nd rised in the smll villge of Ss-Grund in Knton Wllis, Switzerlnd, Krl undertook crpentry work during his school holidys demonstrting mnul nd prcticl skills from n erly ge. Following short stint s ski techer, Krl studied medicine t the University of Bern, nd lter worked s reserch fellow t the AO Reserch Institute (ARI) in Dvos in During this time he focused on investigting the functionl lod of pltes in frcture fixtion in vivo nd its correlte in one heling. Continuous in vivo lod mesurement is still hot topic within the AOTK tody ecuse it might llow for the more ccurte monitoring of frcture heling. Following grdution, Krl strted his professionl creer t the Kntonsspitl Gruünden, under the guidnce of Prof Tom Rüedi nd myself, where he ws immeditely recognized s n outstnding resident. He lter pursued further trining t the Kntonsspitl in St Gllen, nd s reserch fellow t the University of Western Austrli, which strengthened his continued interest in reserch. Krl then decided to seek entirely new chllenges nd moved with his fmily to Austrli more permnently in 2004, firstly working t Fremntle Hospitl, nd lter in the position of Professor for Orthopedic Surgery t the University of Western Austrli in conjunction with consultncy post t Fremntle Hospitl, Rockinghm Generl Hospitl, nd St John of God Murdoch Hospitl. He nd his fmily eventully Krl Stoffel presents on periprosthetic frcture fixtion t the 2nd AOTK Experts Symposium in Seoul, South Kore. Krl during n LEEG ntomy l with Christoph Sommer. AOTK SYSTEM INNOVATIONS 2015

63 PORTRAIT 61 returned to Switzerlnd nd relocted to Bsel, where Krl currently occupies n Associte Professor post t the Kntonsspitl Bsellnd, s well s Tem Leder role for Hip nd Pelvis nd Trumtology. Krl s pssion for innovtion nd development led him to join the AOTK Lower Extremity Expert Group (LEEG) in Under his ledership nd guidnce, new implnt for femorl neck frcture fixtion is currently in development nd will soon e relesed to the mrket. Krl s willingness to tke over extr project tsks is so pronounced tht he hs to e slowed down from time to time in order to protect him from too mny commitments. With PhD in Biomechnics, Krl is the undisputed expert in the LEEG with regrd to estlishing relistic iomechnicl tests for newly developed implnt prototypes. Severl ARI implnt-relted iomechnicl studies re currently proceeding under his supervision. Relizing the importnce of offering etter solutions for periprosthetic frcture tretment, the AOTK (Trum) strted Periprosthetic Frcture Tsk Force in 2014 nd elected Krl s Chir due to his experience s trum nd orthopedic surgeon. After two successful tsk force meetings, the direction is set to design new nil nd plte solutions to ddress periprosthetic femur frctures more effectively. Krl is lso involved in wide rnge of AO eduction ctivities nd serves s fculty in up to six AO courses per yer. He once mentioned tht his grndprents were techers, which explins why teching lies in his lood nd why he is so pssionte out shring his surgicl knowledge with others. Krl dmits to hving two influentil people in his professionl life, oth of whom hve provided invlule technicl nd nlyticl support during his development. While Tom Rüedi nurtured Krl during his erly creer, I m eqully honored to hve worked with such dedicted nd conscientious surgeon. Since joining the Kntonsspitl Gruünden in 1995, Krl hs not only een vlued collegue ut hs ecome gret friend. In his free time Krl enjoys skiing with his fmily, especilly in the re round Ss-Grund. Krl nd his wife Ndine, who works s n osteopth, hve son ged 15 nd two dughters ged 14 nd 11. The whole fmily re pssionte nd tlented skiers nd lso like to go on hiking tours. AOTK very much looks forwrd to continued successful collortion with Krl. Here he is s the entertiner during deprtmentl event in Chur in Krl with wife Ndine nd their children, enjoying skiing trip in Switzerlnd.