- Orthopaedic Surgery
Chief, Pediatric Orthopaedic Surgery, Stanford University (2016 - Present)
Medical Education: Medical University of South Carolina Registrar (1991) SC
Board Certification, American Board of Orthopaedic Surgery, Orthopaedic Surgery
Fellowship, Rady Children's Hospital. San Diego, CA, Pediatric Orthopaedic Surgery (1998)
Residency, Carolinas Medical Center. Charlotte, NC, Orthopaedic Surgery (1997)
Medical Education, Medical University of South Carolina. Charleston, SC (1991)
Tendon Turndown to Bridge a Tibialis Anterior Gap and Restore Active Dorsiflexion After Degloving Foot Injury in a Child: A Case Report.
JBJS case connector
2020; 10 (3): e1900445
CASE: A child with a severe degloving injury to the dorsum of the foot and ankle had segmental loss of the tibialis anterior tendon and toe extensors. A tendon turndown procedure was used, and the repaired tendon was covered with a latissimus muscle free flap to restore active ankle dorsiflexion. Details of the procedure are described, and active dorsiflexion and functional ambulation were restored.CONCLUSIONS: The tendon turndown method is a simple and effective way to overcome segmental tendon loss of tibialis anterior and allowed restoration of active dorsiflexion in this case without relying on tendon transfers or grafting.
View details for DOI 10.2106/JBJS.CC.19.00445
View details for PubMedID 32773712
Does the location of short-arm cast univalve effect pressure of the three-point mould?
Journal of children's orthopaedics
2020; 14 (3): 236–40
Purpose: Forearm and distal radius fractures are among the most common fractures in children. Many fractures are definitively treated with closed reduction and casting, however, the risk for re-displacement is high (7% to 39%). Proper cast application and the three-point moulding technique are modifiable factors that improve the ability of a cast to maintain the fracture reduction. Many providers univalve the cast to accommodate swelling. This study describes how the location of the univalve cut impacts the pressure at three-point mould sites for a typical dorsally displaced distal radius fracture.Methods: We placed nine force-sensing resistors on an arm model to collect pressure data at the three-point mould sites. Sensory inputs were sampled at 15 Hz. Cast padding and a three-point moulded short arm fibreglass cast was applied. The cast was then univalved on the dorsal, volar, radial or ulnar aspect. Pressure recordings were obtained throughout the procedure.Results: A total of 24 casts were analyzed. Casts univalved in the sagittal plane (dorsal or volar surface) retained up to 16% more pressure across the three moulding sites compared with casts univalved in the coronal plane (radial or ulnar border).Conclusion: Maintaining pressure at the three-point mould prevents loss of reduction at the fracture site. This study shows that univalving the cast dorsally or volarly results in less pressure loss at moulding sites. This should improve the chances of maintaining fracture reductions when compared with radial or ulnar cuts in the cast. Sagittal plane univalving of forearm casts is recommended.
View details for DOI 10.1302/1863-2548.14.200034
View details for PubMedID 32582392
Deciding Without Data: Clinical Decision Making in Pediatric Orthopaedic Surgery.
International journal for quality in health care : journal of the International Society for Quality in Health Care
Objective.Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision making, national guidelines, and clinical pathways for many conditions in pediatric orthopaedic surgery are limited. This study investigated decision making rationale and quantified the evidence supporting decisions made by pediatric orthopaedic surgeons in an outpatient clinic.Design/Setting/Participants/Intervention(s)/Main Outcome Measure(s).We recorded decisions made by eight pediatric orthopaedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. "Experience/anecdote", "First Principles", "Trained to do it", "Arbitrary/Instinct", "General Study", "Specific Study").Results.Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were "First principles" (N=310, 27.0%) and "Experience/anecdote" (N=253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.Conclusions.With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence, and help create clinical care pathways in pediatric orthopaedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools & aids could also be implemented to guide these decisions.
View details for DOI 10.1093/intqhc/mzaa119
View details for PubMedID 32986101
- Surveying the POSNA Landscape: What Can We Learn From Society Survey Studies? JOURNAL OF PEDIATRIC ORTHOPAEDICS 2020; 40 (1): E63–E67
Quality Improvement and Patient Safety: How Leadership Can Create a Culture of Safety: AOA Critical Issues Symposium.
The Journal of bone and joint surgery. American volume
Orthopaedic leaders need to create a shared vision and must establish trust, open lines of communication, and buy-in from all team members in order to establish a culture that is supportive of quality improvement. Leaders should encourage teams to follow evidence-based guidelines, reduce variation, take an active role in supply chain processes, and develop new ideas to improve quality and safety of care. With rapidly changing medical and surgical advancements, orthopaedic leaders must continually adapt in the face of evolving challenges.
View details for DOI 10.2106/JBJS.19.01006
View details for PubMedID 31895237
Hoverboard injuries in children and adolescents: results of a multicenter study.
Journal of pediatric orthopedics. Part B
With the increasing popularity of hoverboards in recent years, multiple centers have noted associated orthopaedic injuries of riders. We report the results of a multi-center study regarding hoverboard injuries in children and adolescents. who presented with extremity fractures while riding hoverboards to 12 paediatric orthopaedic centers during a 2-month period were included in the study. Circumstances of the injury, location, severity, associated injuries, and the required treatment were recorded and analysed using descriptive analysis to report the most common injuries. Between-group differences in injury location were examined using chi-squared statistics among (1) children versus adolescents and (2) males versus females. Seventy-eight patients (M/F ratio: 1.8) with average age of 11 ± 2.4 years were included in the study. Of the 78 documented injuries, upper extremity fractures were the most common (84.6%) and the most frequent fracture location overall was at the distal radius and ulna (52.6%), while ankle fractures comprised most of the lower extremity fractures (66.6%). Majority of the distal radius fractures (58.3%) and ankle fractures (62.5%) were treated with immobilization only. Seventeen displaced distal radius fractures and three displaced ankle fractures were treated with closed reduction in the majority of cases (94.1% versus 66.7%, respectively). The distal radius and ulna are the most common fracture location. Use of appropriate protective gear such as wrist guards, as well as adult supervision, may help mitigate the injuries associated with the use of this device; however, further studies are necessary to demonstrate the real effectiveness of these preventions.
View details for DOI 10.1097/BPB.0000000000000653
View details for PubMedID 31503105
Orthopaedic phenotyping of NGLY1 deficiency using an international, family-led disease registry.
Orphanet journal of rare diseases
2019; 14 (1): 148
BACKGROUND: NGLY1 deficiency is a rare autosomal recessive disorder caused by loss in enzymatic function of NGLY1, a peptide N-glycanase that has been shown to play a role in endoplasmic reticulum associated degradation (ERAD). ERAD dysfunction has been implicated in other well-described proteinopathies, such as Alzheimer's disease, Parkinson's disease, and Huntington's disease. The classical clinical tetrad includes developmental delay, hypolacrima, transiently elevated transaminases, and hyperkinetic movement disorders. The musculoskeletal system is also commonly affected, but the orthopaedic phenotype has been incompletely characterized. Best practices for orthopaedic clinical care have not been elucidated and considerable variability has resulted from this lack of evidence base. Our study surveyed patients enrolled in an international registry for NGLY1 deficiency in order to characterize the orthopaedic manifestations, sequelae, and management.RESULTS: Our findings, encompassing the largest cohort for NGLY1 deficiency to date, detail levels of motor milestone achievement; physical exam findings; fracture rates/distribution; frequency of motor skill regression; non-pharmacologic and non-procedural interventions; pharmacologic therapies; and procedural interventions experienced by 29 participants. Regarding the orthopaedic phenotype, at time of survey response, we found that over 40% of patients experienced motor skill regression from their peak. Over 80% of patients had at least one orthopaedic diagnosis, and nearly two-thirds of the total had two or more. More than half of patients older than 6years had sustained a fracture. Related to orthopaedic non-medical management, we found that 93 and 79% of patients had utilized physical therapy and non-operative orthoses, respectively. In turn, the vast majority took at least one medication (including for bone health and antispasmodic therapy). Finally, nearly half of patients had undergone an invasive procedure. Of those older than 6years, two-thirds had one or more procedures. Stratification of these analyses by sex revealed distinctive differences in disease natural history and clinical management course.CONCLUSIONS: These findings describing the orthopaedic natural history and standard of care in patients with NGLY1 deficiency can facilitate diagnosis, inform prognosis, and guide treatment recommendations in an evidence-based manner. Furthermore, the methodology is notable for its partnership with a disease-specific advocacy organization and may be generalizable to other rare disease populations. This study fills a void in the existing literature for this population and this methodology offers a precedent upon which future studies for rare diseases can build.
View details for DOI 10.1186/s13023-019-1131-4
View details for PubMedID 31217022
EMTALA (Emergency Medical Treatment and Active Labor Act) Obligations: A Case Report and Review of the Literature.
The Journal of bone and joint surgery. American volume
2019; 101 (12): e55
The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 in the United States to address "patient dumping," or refusing to provide emergency care to patients and instead transferring them to other hospitals. Under EMTALA, the "reverse-dumping" provision prevents hospitals from refusing patients who require specialized capabilities or facilities if the hospital has the capacity to treat them. Despite this provision, patients continue to be transferred to distant tertiary care centers.We reviewed the literature on EMTALA in the context of a critically ill woman with an infection associated with an orthopaedic implant who was rejected from 2 geographically closer tertiary care centers and was ultimately transferred by helicopter ambulance to an academic teaching hospital that was 169 miles away from her home.After transfer to our tertiary care, level-I trauma center, the patient spent 61 days in the intensive care unit; she required 9 operative procedures, which totaled 1,520 minutes of operative time. Eighteen medical specialties and 8 ancillary medical consulting teams were involved in her care. She underwent 1,436 laboratory and 83 radiographic studies. The total reimbursement from Medi-Cal (California's Medicaid program) for her care in our tertiary care center was $463,753; the hospital charges were more than tenfold higher.Dumping and reverse dumping continue despite compromise of patient care and the high financial burden of the accepting institutions. This may be due to ineffective monitoring and enforcement, lack of uniformity among the courts, and lack of incentive to receive uninsured or poorly funded patients. Under EMTALA, it is difficult for tertiary care centers to argue lack of specialized capabilities or capacity to accept patients, and neither hospitals nor physicians are compensated for the charges of providing care to uninsured or underinsured patients. Moving forward, efforts to better align financial incentives through cost-sharing between community hospitals and tertiary care centers, increased clinician literacy regarding the provisions of EMTALA, and increased transparency with hospital transfers may help improve EMTALA compliance and patient care.
View details for DOI 10.2106/JBJS.18.01166
View details for PubMedID 31220031
Surveying the POSNA Landscape: What Can We Learn From Society Survey Studies?
Journal of pediatric orthopedics
A growing trend of survey-based research has been seen in the field of pediatric orthopaedics. The purpose of this study was to describe patterns of surveys of Pediatric Orthopaedic Society of North America (POSNA) membership and evaluate for associations between study characteristics and response rates in order to inform future research efforts. We hypothesized that studies with fewer survey questions and study group or committee involvement would demonstrate higher response rates.A systematic review of the literature was performed to identify all peer-reviewed survey publications targeting POSNA members published up to December 2017. Included studies were reviewed to identify author and publication characteristics, survey development and methodology, survey distribution procedures, and response rates. Statistical analyses were performed to describe publication patterns and evaluate for associations between study characteristics and response rates.Thirty-four studies published from 1991 to 2017 were identified as meeting inclusion criteria, with a substantial increase noted over the last 3 years. Studies included 4.6 (SD 1.9) authors and 14.7% had affiliations with study groups or committees. Survey development methodology was detailed in only 1 study. Surveys included a median of 19.5 questions (3 to 108) and were primarily electronically distributed. The mean survey response rate was 42% with a downward trend noted over the studied time period. None of the studied author, publication, and design characteristics were associated with increased response rates.Survey-based studies of the POSNA membership have become increasingly popular study designs in recent years. Response rates are lower than reports in other physician cohorts, and appear to be declining, possibly representative of respondent fatigue. No associations were identified between response rates and the modifiable study characteristics evaluated (number of authors, committee or subgroup affiliation, number of questions, and mode of distribution). Efforts should be made to identify tactics to sustain participation as these studies become more widely utilized within our field. Optimizing study design and implementation features while valuing physician time and effort spent on survey completion is important to avoid member survey fatigue.Level V-systematic review of Level V research.
View details for PubMedID 31022015
The Educational Opportunities Provided by a Pediatric Orthopedic Urgent Case Review Conference: Keep Score to Provide a Better Experience
JOURNAL OF SURGICAL EDUCATION
2018; 75 (4): 901–6
To evaluate the distribution of conditions presented at a case conference to assess resident educational exposure to acute pediatric orthopedic conditions.Retrospective review of emergency department and inpatient consultations presented at a daily pediatric orthopedic case conference over a 3-year period. Consultations were divided into 3-month resident rotation blocks for analysis.Tertiary children's hospital in the southern United States which host residents from 2 orthopedic surgery residency programs.The case conference is attended by pediatric orthopedic surgeons, 1 pediatric orthopedic fellow, and 4 PGY III/IV residents.A total of 1762 consultations were presented at the conference. The consultations were obtained for traumatic injuries, 86.5% (1524/1762); infections, 7.7% (136/1762); and congenital/other problems, 5.8% (102/1762). The 3 most common consultations per rotation were fractures: both-bone forearm (mean, 46.1; range: 24-64), supracondylar humerus (mean, 23.8; range: 17-31), and distal radius (mean, 13.8; range: 7-33). Less common consultations per rotation were septic arthritis (mean, 1.6; range: 0-5), child abuse (mean, 1.3; range: 0-5), Monteggia fracture (mean, 0.3; range: 0-1), compartment syndrome (mean, 0.2; range: 0-1) and patella sleeve fracture (mean, 0.1; range: 0-1).There was a large disparity between conditions in the number of times presented and reviewed within a 3-month rotation at the daily case conference, with some important conditions not being discussed at all in each rotation. This finding documents a disadvantage of case conferences based on limiting discussion to current patients, and highlights an opportunity for educational improvement.
View details for PubMedID 29127017
Proximal Tibial Fractures in the Pediatric Population.
The journal of knee surgery
Injuries about the proximal tibia are quite common in children. Understanding the mechanisms of injury and treatment strategies is imperative for practitioners caring for these patients. Similarly, appreciating the anatomy of the proximal tibia and the adjacent neurovascular structures can assist a practitioner in recognizing the potential associated risks following fracture. Patients with injuries about the proximal tibia require long-term follow-up, and knowledge of the natural history of these fractures is imperative.
View details for DOI 10.1055/s-0038-1636911
View details for PubMedID 29514377
Management of Osteochondritis Dissecans of the Femoral Condyle: A Critical Analysis Review.
2018; 6 (3): e5
View details for PubMedID 29557795
The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Supracondylar Humeral Fracture Pearls and Pitfalls
JOURNAL OF ORTHOPAEDIC TRAUMA
2017; 31: S11–S15
Supracondylar humeral fractures are the most common type of pediatric elbow fracture. With proper treatment, these injuries usually heal well and the patients return to full function. However, a small percentage of these injuries may result in devastating complications and, thus, provoke anxiety in many surgeons treating them. This article provides tips for successful management of these injuries without complications and provides references for further study.
View details for PubMedID 29053499
Assessing Quality and Safety in Pediatric Supracondylar Humerus Fracture Care.
Journal of pediatric orthopedics
Recently, there has been an emphasis on improving quality, safety, and value in the delivery of health care in the United States. The American Board of Orthopedic Surgery (ABOS) has developed a performance improvement questionnaire (PIQ) for orthopaedic surgeons managing pediatric supracondylar humerus fracture (PSCHF). Using the supracondylar PIQ as a guide, this study evaluates the process of measuring the outcomes and variations in care to PSCHF patients among pediatric orthopaedic surgeons.An 88-question survey incorporating the ABOS PIQ was administered to 35 pediatric orthopaedic surgeons at 3 institutions. A retrospective chart review of patients who received operative management of a PSCHF during 2013 was performed. Each of the 17 eligible surgeons supplied 5 patients for a total of 85 patients. Medical records and radiographic imaging were reviewed using the ABOS PIQ data collection sheet. This data collection sheet encompasses the preoperative assessment, intraoperative treatment and assessment, and clinical and radiographic outcomes of patients with PSCHF.A total of 35 surgeons from 6 hospitals completed the online PSCHF survey. Uniform consensus among all 35 surgeons was identified in 21/79 of the questions (27%). Consensus among surgeons within a hospital group but not with surgeons from the other groups was identified in 39/79 (49%) of the questions. No consensus among the surveyed surgeons could be identified in 19/79 (24%) of the questions. For the 85 PSCHF patients the average age was 6 years, and 37% of fractures were type II, 57% of fractures were type III, and there was 1 flexion type. Ninety percent of the patients received a preoperative dose of antibiotics and the postoperative immobilization placed in the operating room was changed in the clinic before pin removal in 58% of the cases. Pins were removed at 3 weeks in 60%, 4 weeks in 30%, 5 weeks in 7%, and after 5 weeks in 3% of the patients and no malunions occurred. Pin tract infection occurred in 2 patients (2.4%). The procedure time ranged from 13 to 171 minutes, with a median time of 37 minutes. Total anesthesia time ranged from 32 to 233 minutes, with a median of 72 minutes. The number of outpatient follow-up visits ranged from 2 to 7 visits, with a median of 3 visits. The number of postoperative radiographs obtained ranged from 1 to 14, with a median of 3 studies. Four patients (5%) returned to the operating room for a repeat surgery.The survey responses from the surgeons at 6 different hospitals demonstrate that there is still considerable variation in care among surgeons, even for such a routine injury. Our chart review also revealed substantial variation in care with subsequent quality and cost-implications. The variations in operating room time, anesthesiology time, number of postoperative visits, number of radiographs ordered, and the initial intraoperative immobilization, all point to opportunities for standardization and lowering of costs.Level IV.
View details for DOI 10.1097/BPO.0000000000000992
View details for PubMedID 28399047
Design and descriptive data of the randomized Clubfoot Foot Abduction Brace Length of Treatment Study (FAB24).
Journal of pediatric orthopedics. Part B
2017; 26 (2): 101-107
The aim of this study was to describe the design and baseline characteristics of participants enrolled in the prospective randomized-controlled Clubfoot Foot Abduction Brace Length of Treatment Study (FAB24). Foot abduction bracing is currently the standard of care for preventing clubfoot relapse. Current recommendations include full-time bracing for the first 3 months and then 8-12 h a day for 4 years; however, the optimal length of bracing is not known. The FAB24 trial is a clinical randomized study to determine the effectiveness of 2- versus 4-year foot abduction bracing. Participant enrollment for FAB24 was conducted at eight sites in North America and included enrollment and randomization of 139 participants with isolated clubfoot. This clinical trial will generate evidence-based data that will inform and improve patient care.
View details for DOI 10.1097/BPB.0000000000000387
View details for PubMedID 27632641
Restoration of Blood Flow to the Proximal Femoral Epiphysis in Unstable Slipped Capital Femoral Epiphysis by Modified Dunn Procedure: A Preliminary Angiographic and Intracranial Pressure Monitoring Study.
Journal of pediatric orthopedics
The major complication of unstable slipped capital femoral epiphysis (SCFE) is avascular necrosis (AVN) of the femoral head. The purpose of this study was to document by angiography the preoperative and postoperative perfusion to the proximal femoral epiphysis following an unstable SCFE. A specific aim was to determine whether blood flow could be restored. A secondary aim was to determine the efficacy of an intracranial pressure (ICP) monitor to assess blood flow within the femoral head intraoperatively.Nine patients with an unstable SCFE underwent superselective angiogram of the medial circumflex femoral artery preoperatively, followed by operative fixation with an open reduction using a modified Dunn approach. Femoral head blood flow was evaluated with an ICP monitor. Angiography was repeated postoperatively. Patients were followed radiographically to assess for AVN.Follow-up averaged 22 months. Six patients did not have arterial flow to the femoral head on the preoperative angiogram. Flow was restored postoperatively on angiogram in 4 of the 6 patients. Two patients developed AVN. One had no flow to the femoral head preoperatively or postoperatively on angiogram and complete tearing of the periosteum was noted. In 1 patient, there was no ICP waveform after the initial reduction. After removing more callous and repeating reduction, the waveform returned. Of the 2 patients with AVN, 1 had an ICP waveform after reduction.This study documents that some patients with unstable SCFE present with reduced femoral head blood supply due to SCFE. It also demonstrates blood flow restoration in 4 patients by angiogram and 5 by ICP monitor after surgical treatment. No patient immediately lost blood flow due to surgery. ICP monitor is a safe intraoperative tool for real-time assessment of femoral head blood flow during open reduction of unstable SCFE. Presence of flow by ICP is not a guarantee that AVN will not develop, but absence of flow was predictive of AVN.Therapeutic level I-prognostic. See Instructions for Authors for a complete description of levels of evidence.
View details for PubMedID 27177236
A survey of resident perspectives on surgical case minimums and the impact on milestones, graduation, credentialing, and preparation for practice: AOA critical issues.
journal of bone and joint surgery. American volume
2014; 96 (23)
Residency education continues to evolve. Several major changes have occurred in the past several years, including emphasis on core competencies, duty-hour restrictions, and call. The Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System (NAS) implemented educational milestones in orthopaedic surgery in July 2013. Additionally, the Residency Review Committee for orthopaedic surgery published suggested surgical case minimums in 2012, which overlap with several of the milestones.We conducted a survey to assess the opinions of orthopaedic residents regarding the ACGME-suggested surgical case minimums and the effects that these may have on resident education and potential future privileges in hospitals. The survey was sent via e-mail to all of the residents participating in the American Orthopaedic Association (AOA) Resident Leadership Forum for both 2011 and 2012. Participants in the Resident Leadership Forum are in either postgraduate year 4 or postgraduate year 5, are selected by the program directors as resident leaders, and represent 80% of the orthopaedic residency programs in the United States. The survey was completed by 157 of the 314 participants. Sixty-nine percent of the participants believed that case logs with minimum numbers of surgical procedures were an effective way to monitor the work but were not necessarily the only way to monitor the educational progress of the residents. Thirty-two percent believed that the minimums should not be required. Overwhelmingly, there was agreement that important cases were missing from the currently proposed sixteen core surgical minimums. Specifically, the residents believed that a minimum number of cases are necessary for distal radial fracture fixation and proximal humeral fracture fixation and possibly have a milestone to reflect the progress of the residents for each fixation.Most residents thought that surgical case minimums are an effective tool in monitoring the progress of residents and measuring the effectiveness of residency programs. However, the surgical ability of an individual resident should not be evaluated on case minimums alone. The development of the milestones to assess competency should continue, but, as surgical skill is not a specific core competency, perhaps other methods for assessing surgical proficiency need to be developed rather than case minimums. Surgical skills laboratories and proctoring residents independently performing procedures may help to assess surgical proficiency, in addition to traditional faculty and 360° evaluations. Combining these types of assessments with surgical case logs documenting the residents' educational experience seems to be the best path going forward in assessing the development of young surgeons.
View details for DOI 10.2106/JBJS.N.00044
View details for PubMedID 25471921
Assessing the Value of Work Done by an Orthopedic Resident During Call.
Journal of graduate medical education
2014; 6 (3): 567-570
Medicare funding for graduate medical education may be cut in the next federal budget.We quantified the value of work that 1 orthopedic surgery resident performs on call and compare it to Medicare educational funding received by the hospital for each resident.A single orthopedic resident's on-call emergency department and inpatient consults were collected during a 2-year call period at a large, tertiary, level-1 trauma center. Patient charts were reviewed; ICD-9 codes, evaluation and management, and procedural treatment were recorded. Codes were converted into work relative value units. The number of work relative value units was multiplied by the 2012 Medicare rate of $34.03 per relative value units to calculate the monetary value of resident work.Of 120 resident call shifts, 115 call sheets (95.8%) were available for review, and 1160 patients were seen (average = 10.09 consults/call). A total of 4688 work relative value units were generated (average = 40.76 per night), and the total dollar value generated was $159,561 ($1,387 per call) during the 2 years of call (average = $79,780 annually). Evaluation and management codes generated 2340 work relative value units, with a calculated dollar amount of $79,648, and procedural codes generated 2348 work relative value units, with a calculated dollar amount of $79,913.Our institution estimated Medicare direct medical education support per resident at $40,000/y, and total funding was $130,000/resident. At our tertiary care institution, the unbilled work of 1 orthopedic resident on call amounts to more than 60% of Medicare direct medical education and indirect medical education funding annually.
View details for DOI 10.4300/JGME-D-13-00370.1
View details for PubMedID 26279786
- Should you explore the brachial artery in children who have a perfused hand but no palpable radial pulse after sustaining a supracondylar humeral fracture? Commentary on articles by Amanda Weller, MD, et al.: Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary?" and Brian P. Scannell, MD, et al.: "The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function". journal of bone and joint surgery. American volume 2013; 95 (21)
The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function.
journal of bone and joint surgery. American volume
2013; 95 (21): 1913-1919
This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation.Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold.Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score.After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery.Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.
View details for DOI 10.2106/JBJS.L.01584
View details for PubMedID 24196460
Copy number analysis of 413 isolated talipes equinovarus patients suggests role for transcriptional regulators of early limb development
EUROPEAN JOURNAL OF HUMAN GENETICS
2013; 21 (4): 373-380
Talipes equinovarus is one of the most common congenital musculoskeletal anomalies and has a worldwide incidence of 1 in 1000 births. A genetic predisposition to talipes equinovarus is evidenced by the high concordance rate in twin studies and the increased risk to first-degree relatives. Despite the frequency of isolated talipes equinovarus and the strong evidence of a genetic basis for the disorder, few causative genes have been identified. To identify rare and/or recurrent copy number variants, we performed a genome-wide screen for deletions and duplications in 413 isolated talipes equinovarus patients using the Affymetrix 6.0 array. Segregation analysis within families and gene expression in mouse E12.5 limb buds were used to determine the significance of copy number variants. We identified 74 rare, gene-containing copy number variants that were present in talipes equinovarus probands and not present in 759 controls or in the Database of Genomic Variants. The overall frequency of copy number variants was similar between talipes equinovarus patients compared with controls. Twelve rare copy number variants segregate with talipes equinovarus in multiplex pedigrees, and contain the developmentally expressed transcription factors and transcriptional regulators PITX1, TBX4, HOXC13, UTX, CHD (chromodomain protein)1, and RIPPLY2. Although our results do not support a major role for recurrent copy number variations in the etiology of isolated talipes equinovarus, they do suggest a role for genes involved in early embryonic patterning in some families that can now be tested with large-scale sequencing methods.
View details for DOI 10.1038/ejhg.2012.177
View details for Web of Science ID 000317089300005
View details for PubMedID 22892537
View details for PubMedCentralID PMC3598331
- Orthopaedic surgery milestones. Journal of graduate medical education 2013; 5 (1): 36-58
Obesity in pediatric orthopaedics.
Orthopedic clinics of North America
2011; 42 (1): 95-?
Obesity is a rapidly expanding health problem in children and adolescents and is the most prevalent nutritional problem for children in the United States. Some believe that obesity has become a major epidemic in American children, with the prevalence having more than doubled since 1980. This epidemic has led to a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to $237.6 million between 2001 and 2005. This article describes some of the orthopaedic conditions commonly encountered in overweight/obese children and adolescents, classically infantile and adolescent tibia vara and slipped capital femoral epiphysis. Also discussed are genu valgum, which has been associated with obesity, and other difficulties encountered in providing orthopaedic care to obese children.
View details for DOI 10.1016/j.ocl.2010.08.005
View details for PubMedID 21095438
- Workforce, work, and advocacy issues in pediatric orthopaedics. journal of bone and joint surgery. American volume 2010; 92 (17)
The Drop Toe Sign: An Indicator of Neurologic Impairment in Congenital Clubfoot
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
2009; 467 (5): 1238-1242
Nine patients presenting during infancy were identified with clubfeet and absent anterior and lateral compartment functions. We considered these to be neurogenic clubfeet. All patients had the drop toe sign: resting posture of the toes in plantarflexion and absent active dorsiflexion movement after plantar stimulation of the foot. Two patients (three feet) underwent exploration of the peroneal nerve, which revealed anatomic abnormalities. Six patients required more casts than typical for initial correction of deformity; all but two had Achilles tenotomy. Four relapsed despite full-time bracing and eventually needed intraarticular surgery to achieve a plantigrade foot. Idiopathic absent peroneal nerve function is not a well-described entity in the clubfoot literature. All babies with clubfoot should be examined for the drop toe sign. When noted, the feet will likely be more difficult to correct initially, may need early Achilles tendon lengthening, will likely need permanent bracing, are likely to relapse and need intraarticular surgery, and may need multiple surgeries to remain plantigrade throughout growth.Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
View details for DOI 10.1007/s11999-008-0690-9
View details for Web of Science ID 000264854300017
View details for PubMedID 19130157
- An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. journal of bone and joint surgery. American volume 2008; 90 (5): 1143-1159
Impact of anaesthesia-surgery on D-dimer concentration and end-tidal CO2 and O-2 in patients undergoing surgery associated with high risk for pulmonary embolism
CLINICAL PHYSIOLOGY AND FUNCTIONAL IMAGING
2008; 28 (3): 161-168
The exhaled end-tidal CO2/O2 ratio and the D-dimer concentration are diagnostic markers of pulmonary embolism (PE).To develop a non-invasive technique to monitor for PE in surgical patients. We examine the change imparted by anaesthesia-surgery on the end-tidal CO2/O2 compared with the D-dimer.We enrolled 125 participants undergoing an orthopaedic or oncological operation thought to confer high risk for postoperative PE. We obtained preoperative blood samples in the anaesthesia clinic, and breath samples in the preoperative holding area on the same day of surgery; we repeated blood and breath samples on the postoperative day of discharge. Blood samples were immediately analysed for fibrinogen and D-dimer (Vidas; bioMérieux, Durham, NC, USA) concentrations. Breath samples were obtained from 1 min of spontaneous tidal breaths delivered via mouthpiece while the participant breathed room air. All participants had follow-up at 30 days.We enrolled 125 participants and had complete data in 104. No participant developed PE or deep venous thrombosis within 30 days. The mean preoperative D-dimer was 927 +/- 928 ng ml(-1), and the mean postoperative D-dimer was 1879 +/- 1263 ng ml(-1) and the mean relative change was +234 +/- 292%. The mean preoperative end-tidal CO2/O2 was 0.31 +/- 0.05 and the mean postoperative end-tidal CO2/O2 was 0.32 +/- 0.07 and the mean relative change was +1.6 +/- 20%. The increase in D-dimer did not correlate with the increase in fibrinogen (r2 = 0.015).The stress impact of anaesthesia-surgery causes less change in end-tidal CO2/O2 compared with the D-dimer. Further work will be required to determine if end-tidal CO2/O2 can be used to monitor for postoperative PE.
View details for DOI 10.1111/j.1475-097X.2008.00789.x
View details for Web of Science ID 000254807900004
View details for PubMedID 18279423
Sequelae of pediatric hip disorders: survey responses from experts in adult hip reconstruction.
American journal of orthopedics (Belle Mead, N.J.)
2008; 37 (3): 153-156
Questions persist concerning the incidence of total hip arthroplasties (THAs) attributable to secondary osteoarthrosis and the impact of corrective pediatric hip surgeries and retained internal fixation on subsequent THAs. Hip reconstruction fellowship directors (N = 72) were mailed a survey of multiple-choice questions about pediatric hip disorders (PHDs) in their THA populations, the influence of hip osteotomies on subsequent THAs, and the recommendation to routinely remove pediatric hip internal fixation. Forty-five surgeons (62.5%) responded. The majority reported that a small proportion of hip arthrosis in their practice was attributable to PHDs (10-30 cases per 100-200 annual cases). Fifty-seven percent indicated that hip surgery performed during skeletal immaturity made THA more difficult. Twenty-eight surgeons (62% of respondents) said that they remove implants from fewer than 10% of cases with previous pediatric surgery. Sixty-eight percent felt that removal of pediatric hip implants, particularly those in the proximal femur (83% of respondents), should be routine. Survey results showed that the majority of experts in adult hip reconstruction (a) do not identify PHDs as a significant factor in most of their patients with end-stage hip arthrosis and (b) believe in routine removal of pediatric hip implants, particularly those in the proximal femur. The impact of performing corrective hip surgery during skeletal immaturity--whether such surgery increases the difficulty of or diminishes the effectiveness of subsequent THA--remains controversial.
View details for PubMedID 18438471
- The 2007 ABC Traveling Fellowship: building international orthopaedic bridges. journal of bone and joint surgery. American volume 2008; 90 (3): 672-674
Results of the Ponseti method in patients with clubfoot associated with arthrogryposis.
The Iowa orthopaedic journal
2008; 28: 22-26
Clubfoot associated with arthrogryposis has been traditionally considered very resistant to manipulation and casting, and therefore has required surgical correction. The purpose of this study was to evaluate the results of the Ponseti method of clubfoot casting in this patient population. We reviewed the records of patients with clubfoot associated with arthrogryposis consecutively treated at our respective institutions from January 1992 to December 2004. All patients were treated by serial manipulations and casting following the principles of the Ponseti method. Main outcome measures included initial correction of the deformity, relapses and the need for surgical releases or any other surgeries. Average age at last follow up was 4.6 years. There were 16 patients, all with bilateral deformities (32 clubfeet). there were 11 males and 5 females. Nine patients had both upper and lower extremity involvement. Seven patients had previous treatment elsewhere and one patient had an Achilles tenotomy. Initial correction was obtained in all but 1 patient. Average number of casts required for correction was 7 (range: 5 to 12). Average post-tenotomy dorsiflexion was 5 degrees. One patient required a posterior-medial release (PMR) for insufficient initial correction. Four cases required subsequent surgery for relapses (1 bilateral PMR with a repeat left PMR; 2 posterior releases (PR), 1 PR and anterior tibialis transfer (ATT), and 1 ATT). No talectomies were required. This study demonstrates that the Ponseti method is very effective for the correction of patients with clubfoot associated to arthrogryposis. Although this deformity is more rigid than in idiopathic clubfoot, many cases can be corrected when started in the first few weeks after birth.
View details for PubMedID 19223944
Advances in the surgical management of pediatric femoral shaft fractures
CURRENT OPINION IN PEDIATRICS
2007; 19 (1): 51-57
To provide an update on surgical methods of pediatric femur fracture treatment.Multiple studies describe successful results with elastic nail stabilization of pediatric femur fractures. The indications and risk factors for complications are being more clearly defined. Trochanteric entry-locked intramedullary nailing and submuscular bridge plating have also recently been reported to produce excellent outcomes in a high percentage of patients. Older (>11 years) patients, heavier patients and patients with length-unstable fracture patterns may be best treated with locked nailing or plating.Pediatric femur fractures can be successfully treated by a number of methods. This review examines the recent literature to provide some guidelines for choosing amongst the options for surgical stabilization.
View details for Web of Science ID 000243870800008
View details for PubMedID 17224662
Evaluation of the child who has hip pain
ORTHOPEDIC CLINICS OF NORTH AMERICA
2006; 37 (2): 133-?
Evaluation of children who have hip pain can be a diagnostic challenge. This article reviews pertinent history taking, physical examination, laboratory testing, and imaging studies that assist in reaching a correct diagnosis. It also reviews the diagnostic categories that are important in formulating a differential diagnosis to frame clinical decision making.
View details for DOI 10.1016/j.ocl.2005.12.003
View details for Web of Science ID 000237210300003
View details for PubMedID 16638444
Ponsetii management of Clubfoot in older infants
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Treatment of clubfoot with the Ponseti method is successful when performed immediately after birth. We treated 23 infants (36 feet) who presented to us after casting, applied at other institutions, failed or after 3 months of age. Twenty-two infants had serial casting started during the first 2 months, and one infant who was 6 months old at presentation had not received previous treatment. The original orthopaedists of 18 patients advised posteromedial release. The parameter studied was the need for posteromedial release (ie, failure of Ponseti casting and percutaneous Achilles tenotomy to obtain satisfactory clinical appearance). Only one (2.8%) of 36 feet required open surgical release (posterior only). Thirty-five feet required percutaneous Achilles tenotomy. A mean of six Ponseti casts were applied before tenotomy. Two feet (two infants) required anterior tibialis transfer for mild relapse; three other feet (two infants) required repeat casting for mild relapse. Most pediatric orthopaedists think that successful clubfoot casting depends on treatment started immediately after birth. Our data suggest that older infants with clubfoot can be treated successfully without extensive surgery. Our results in older infants are similar to the results of a previous study we conducted with younger infants. In that study, one (2.9%) of 34 feet required posteromedial release surgery.Therapeutic study, Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.
View details for DOI 10.1097/01.blo.0000201147.12292.6b
View details for Web of Science ID 000243020200032
View details for PubMedID 16456307
Gene expression during fracture healing in rats comparing intramedullary fixation to plate fixation by DNA microarray
JOURNAL OF ORTHOPAEDIC TRAUMA
2006; 20 (1): 27-38
This study was designed to compare mRNA gene expression in healing diaphyseal femoral fractures between those injuries treated with intramedullary nails and those treated with internal plate fixation.RNA gene expression was measured at 1 day, 3 days, and 1, 2, 4, and 6 weeks after surgery in the fracture callus of rats randomized to femoral shaft fracture with intramedullary nail fixation, rigid plate fixation, or sham fracture.AAALAC-accredited vivarium of an independent academic medical center.Fifty-seven, adult, female, Sprague-Dawley rats at 16 weeks of age.Femoral fracture with intramedullary nail fixation, femoral fracture with plate and screw fixation, or sham surgery with no fracture.RNA expression for 8700 genes was measured with 19 Affymetrix U34A microarrays. The fracture callus was significantly larger with intramedullary nail fixation than with plate fixation. Most genes responded to fracture with a change in mRNA expression. Most of the responding genes followed the same time course for both fixation methods. This included genes related to growth factors, bone matrix, mast cells, most nerve factors, and hematopoiesis. The intramedullary nail group had significantly greater up-regulation for transcripts related to cartilage, cell division, inflammation, and the acetylcholine receptor. There was significantly greater up-regulation in the plate group for genes related to macrophage activity.There were differentially expressed genes present between the 2 surgical groups that may give insight into the control of fracture repair.
View details for Web of Science ID 000235495200006
View details for PubMedID 16424807
The ponseti method of treatment for congenital clubfoot: Importance of maximal forefoot supination in initial casting
2005; 28 (1): 63-65
The correction of cavus deformity requires further supination of the forefoot. In the Ponseti method, the initial cast is applied with the forefoot supinated such that the plane of the metatarsal heads is parallel to the long axis of the tibia. This study reviewed Pirani scores of 27 patients with 38 clubfeet treated over an 18-month period by the Ponseti method to evaluate changes in midfoot deformity after the initial cast. Initial average scores for severity of the lateral border deformity, medial crease, and talonavicular joint reducibility decreased from 0.92, 0.75, and 0.75, respectively, to 0.73, 0.25, and 0.5, respectively, after the first cast. The improvement in Pirani scores provides support for the efficacy of the initial cast to reduce the cavus and also increase the reducibility of the midfoot. Failure to address the cavus deformity with the initial cast as described by Ponseti may lead to persistent rigidity and incomplete correction.
View details for Web of Science ID 000226328200010
View details for PubMedID 15682578
Informed consent is not routinely documented for procedures using allografts
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Patients who receive musculoskeletal allografts may have severe postoperative infections develop. Media reports have heightened public awareness of the risk of allograft use. Explaining these risks to patients preoperatively has become more important as attention to informed consent issues has increased. This study retrospectively investigated the patterns of informed consent for allograft bone used during elective orthopaedic procedures at a major teaching hospital. Forty-seven (32%) of 148 patients had preoperative discussions of allograft risks and benefits documented with a signed preoperative consent. In nearly 70% of the cases in which structural allograft was used, preoperative consent was documented. Only 8% of cases in which nonstructural, highly processed allograft was used had documented preoperative consent. Forty-eight (32%) of 148 patients were treated with allograft and autograft. Consent was obtained for the harvesting and use of autograft from 90% of these patients. In none of these patients was consent obtained for the allograft used. Although risks of disease transmission vary widely with the degree of allograft processing and the source of its procurement, informed consent for any allograft use should be a routine part of preoperative discussions of risks and benefits in elective orthopaedic surgeries.
View details for DOI 10.1097/01.blo.0000130201.44637.aa
View details for Web of Science ID 000222095100047
View details for PubMedID 15232464
Valgus deformity after fibular resection in children.
Journal of pediatric orthopedics
2004; 24 (3): 345-?
View details for PubMedID 15105744
Compartment syndrome of the leg after treatment of a femoral fracture with an early sitting spica cast. A report of two cases.
journal of bone and joint surgery. American volume
2003; 85-A (11): 2207-2210
View details for PubMedID 14630855
Spinal osteochondroma presenting as atypical spinal curvature: a case report.
2003; 28 (13): E252-5
The case of an 8-year-old girl with hereditary multiple exostosis presenting with atypical spinal curvature is reported.To describe a case of spinal curvature caused by an osteochondroma, illustrating the need for careful evaluation of patients with hereditary multiple exostosis presenting with "scoliosis."Osteochondromas have been known to arise in the spinal canal and to present with symptoms of neural compression. Spinal curvature is a rare presenting sign of osteochondromas.The patient's medical and radiographic history is reviewed as well as the medical literature.An 8-year-old girl with hereditary multiple exostosis was referred for possible thoracotomy and anterior decompression of a T4 osteochondroma thought to be causing an atypical "scoliosis." Further examination, review of the radiographs, and computed tomography scan showed a large L4 osteochondroma encroaching on the neural elements. The patient's neurologic symptoms and spinal curvature resolved in the 2 years after surgical excision of the lumbar osteochondroma.Patients with hereditary multiple exostosis and spinal curvature require further diagnostic evaluation to ensure that an osteochondroma in the spinal canal is not the cause of that curvature.
View details for PubMedID 12838114
Femoral anteversion in children with cerebral palsy. Assessment with two and three-dimensional computed tomography scans.
journal of bone and joint surgery. American volume
2003; 85-A (3): 481-488
Assessment of femoral anteversion in children with cerebral palsy with two or three-dimensional computed tomography scans may be limited by both positional and anatomic variables. Three-dimensional computed tomography techniques are considered to be more accurate than two-dimensional imaging when the femur is not optimally positioned in the gantry or when the neck-shaft angle is increased.Computed tomography scanning was performed on a series of nine model femora with anteversion ranging from 20 degrees to 60 degrees and neck-shaft angles ranging from 120 degrees to 160 degrees. Each femoral model was scanned in two holding devices, the first of which held the femur in optimal alignment (normal model) and the second of which held the femur in flexion, adduction, and internal rotation (cerebral palsy model) relative to the gantry. Femoral anteversion was calculated for each model from two and three-dimensional computed tomography scans by four examiners on two separate occasions. The intraobserver and interobserver reliability, the accuracy, and the effect of increasing the neck-shaft angle on the accuracy of the measurements made on the two and three-dimensional scans of the normal and cerebral palsy models were then examined.The mean differences in the measurements of femoral anteversion made by the same examiner (intraobserver reliability) were <2 degrees for the two-dimensional scans of the normal and cerebral palsy models and the three-dimensional scans of the normal models, and the mean difference was <4 degrees for the three-dimensional scans of the cerebral palsy models. The mean differences among examiners (interobserver reliability) were <3 degrees for the two-dimensional scans of the normal and cerebral palsy models and the three-dimensional scans of the normal models, and the mean difference was <6 degrees for the three-dimensional scans of the cerebral palsy models. The accuracy of the assessments of femoral anteversion of the normally aligned models was comparable between the two and three-dimensional scans. However, the three-dimensional assessment was significantly more accurate than the two-dimensional assessment for measurement of anteversion of the cerebral palsy models (p = 0.003). Accuracy within 5 degrees was comparable between the two and three-dimensional scans for measurement of the normally aligned models, with 86% of the two-dimensional measurements and 78% of the three-dimensional measurements falling within 5 degrees of the actual measurements. However, the accuracy within 5 degrees was significantly compromised when the models were placed in cerebral palsy alignment. Only 3% of the two-dimensional measurements and 14% of the three-dimensional measurements fell within 5 degrees of the actual measurements, with three-dimensional assessment being significantly better than two-dimensional assessment (p = 0.006). Increasing the neck-shaft angle did not significantly compromise the accuracy of measurement of femoral anteversion with either the two-dimensional or the three-dimensional technique (p > 0.05 for all comparisons).When adequate alignment of the femur in the computed tomography scanner was possible, a simple two-dimensional technique exhibited excellent intraobserver and interobserver reliability and clinically acceptable accuracy within the relevant ranges of anatomic variability tested (neck-shaft angles of 120 degrees to 160 degrees and femoral anteversion of 20 degrees to 60 degrees). When optimal alignment of the femur in the scanner was not possible, neither two-dimensional nor three-dimensional techniques exhibited clinically acceptable accuracy for the measurement of femoral anteversion.
View details for PubMedID 12637435
Surgical correction of residual hip dysplasia in two pediatric age-groups.
journal of bone and joint surgery. American volume
2002; 84-A (7): 1148-1156
The goal of operative treatment of hip dysplasia or subluxation in children is to normalize the hip joint to delay or prevent the premature onset of osteoarthritis. In theory, intervention in early childhood, when the remodeling potential is greater, should provide the best opportunity for the development of a normal joint.To determine the efficacy of early surgical intervention in restoring the normal morphology of the hip, according to radiographic criteria, we reviewed the cases of thirty-six children (fifty hips) with residual dysplasia or subluxation who were managed with either a femoral and/or a pelvic osteotomy when they were between two and eight years old (Group I). The average age at the time of surgery was 3.7 years, and the average duration of follow-up was 4.3 years. We compared these results with those achieved in fourteen patients (eighteen hips) with residual hip dysplasia or subluxation who were treated surgically at an older age, between eight and eighteen years old (Group II). The outcome was assessed with use of clinical as well as multiple radiographic criteria. We believe that a normal relationship between the acetabulum and the femoral head was established when there was an acetabular index of <20 degrees or a Sharp angle of <42 degrees, a center-edge angle of >20 degrees, and an intact Shenton's line.At the time of the latest follow-up, sixteen of the seventeen hips with residual dysplasia that had been treated with pelvic osteotomy alone in Group I and three of four such hips in Group II had a normal relationship between the acetabulum and the femoral head. Normal radiographic findings were noted in fifteen of the seventeen hips with residual subluxation that had been treated with combined femoral and pelvic osteotomies in Group I compared with four of eight such hips in Group II.We found that residual hip dysplasia or subluxation could be more predictably corrected, with normal radiographic results and with less morbidity and fewer complications, in children who were between two and eight years old than in those who were between eight and eighteen years old. Long-term follow-up is required to confirm whether the improved anatomy and function of the hip that resulted from early correction of residual dysplasia or subluxation lasts into adulthood.
View details for PubMedID 12107314
AOA 2001 John J. Fahey, MD, Memorial North American Traveling Fellowship: fellows' travel diary.
journal of bone and joint surgery. American volume
2002; 84-A (5): 854-862
View details for PubMedID 12004031
- Bilateral quadriceps tendon rupture as the initial presentation of amyloidosis ORTHOPEDICS 2001; 24 (10): 995-996
Altered fibular growth patterns after tibiofibular synostosis in children.
journal of bone and joint surgery. American volume
2001; 83-A (2): 247-254
Iatrogenic synostosis of the tibia and fibula following an operation on the leg in a child has been reported rarely in the literature, and the effects of this complication on future growth, alignment, and function are not known. This is a retrospective case series, from one institution, of crossunions of the distal parts of the tibia and fibula complicating operations on the leg in children. The purpose is to alert surgeons to this possible complication.The senior author identified eight cases of iatrogenic tibiofibular synostosis seen in children since 1985. The patients had various diagnoses and were from the practices of four pediatric orthopaedic surgeons. Synostosis developed in six patients after osteotomies of the distal parts of the tibia and fibula, in one after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision, and in one after posterior transfer of the anterior tibialis tendon through the interosseous membrane combined with peroneus brevis transfer to the calcaneus. Medical records were reviewed, and preoperative and follow-up radiographs were analyzed for changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle.Five patients were symptomatic after crossunion; they presented with prominence of the proximal part of the fibula, ankle deformity, or ankle pain. Three patients were asymptomatic, and a synostosis was identified on routine follow-up radiographs. Intraoperative technical errors caused two of the crossunions; the cause of the others was unknown. Following tibiofibular synostosis, growth disturbances were noted radiographically in every patient. The normal growth pattern of distal migration of the fibula relative to the tibia was reversed, resulting in a decreased distance between the proximal physes of the tibia and fibula as well as proximal migration of the distal fibular physis relative to the distal part of the tibia. Shortening of the lateral malleolus led to greater valgus alignment of the ankle.Tibiofibular synostosis can complicate an operation on the leg in a child. After crossunion, the normal distal movement of the fibula relative to the tibia is disrupted, resulting in shortening of the lateral malleolus and ankle valgus as well as prominence of the fibular head at the knee. The synostosis also interferes with the normal motion that occurs between the tibia and fibula with weight-bearing, potentially leading to ankle pain.
View details for PubMedID 11216687
Pre- and postoperative three-dimensional computed tomography analysis of triple innominate osteotomy for hip dysplasia
JOURNAL OF PEDIATRIC ORTHOPAEDICS
2000; 20 (1): 116-123
Traditional methods of analysis and surgical techniques for hip dysplasia concentrate on frontal-plane analysis of the hip. More recent studies on imaging and operative correction of hip dysplasia recommend three-dimensional (3D) analysis, and some have mentioned but not emphasized the importance of transverse-plane acetabular anatomy (anteversion/retroversion). In this study we found that failure to analyze and understand transverse-plane acetabular anatomy can contribute to complications after triple innominate osteotomy (TIO). A subset of seven patients (eight hips) who were treated with TIO for deficient acetabular coverage resulting from hip dysplasia or Legg-Calvé-Perthes disease had both pre- and postoperative 3D computed tomography (CT) studies. Most of the postoperative studies were obtained to analyze complications (external limb rotation, nonunion). Analysis of the 3D CT studies showed a change in the position of the acetabular fragment after osteotomy into greater adduction, anterior rotation (extension), and external rotation, improving femoral head coverage. All of the hips had increased external rotation of the acetabulum after TIO. Excessive external rotation (>10 degrees) was noted in five hips, and these included two hips with pubic osteotomy nonunion, two with ischial nonunion, and one with marked external rotation of the lower limb. External rotation of the acetabular fragment during redirectional pelvic osteotomy can result in (a) excessive external rotation of the lower limb, (b) decreased posterior coverage, (c) increased gaps at the pubic and/or ischial osteotomy sites with resultant higher rates of nonunion, and (d) lateralization of the joint center. The surgical technique for TIO should be designed to avoid excessive external rotation of the acetabular fragment.
View details for Web of Science ID 000084469100023
View details for PubMedID 10641700
- Scheuermann kyphosis SPINE 1999; 24 (24): 2630-2639
Early surgical correction of residual hip dysplasia: the San Diego Children's Hospital approach.
Acta orthopaedica Belgica
1999; 65 (3): 277-287
Studies of the etiology of premature osteoarthritis of the hip show that the most common cause is residual childhood hip dysplasia. Hip dysplasia is often asymptomatic in childhood, making detection difficult and creating complex treatment decisions (major surgery in the asymptomatic child). Symptoms do not develop typically until the teenage or early adult years, and surgical correction at this age is often incomplete and complicated. In contrast, if the dysplasia is recognized early, surgical correction can be performed using simpler osteotomies with more predictable results. Our experience with children, adolescents and adults with residual hip dysplasia has led us to adopt a philosophy of early surgical correction which seeks to normalize hip joint morphology by age 5 or 6 years. The reasoning, methods and early results of this approach are reviewed in this paper.
View details for PubMedID 10546350
Anteversion of the acetabulum in developmental dysplasia of the hip: Analysis with computed tomography
JOURNAL OF PEDIATRIC ORTHOPAEDICS
1999; 19 (4): 438-442
Acetabular anteversion was measured by using two-dimensional (2-D) computed tomography (CT) scans in 39 dysplastic and 27 normal hips (patient age range, 3-33 years), and averaged 19.7 degrees in the dysplastic hips and 18.1 degrees in the normal hips. There was no statistically significant difference between the two groups, with a wide range of acetabular anteversion values noted in both groups (8-32 degrees ). Although acetabular anteversion may be increased in some patients with developmental dysplasia of the hip (DDH), it is not a universal finding. We believe that assessment and understanding of acetabular anteversion is needed before performing corrective osteotomies for hip dysplasia to optimize results and avoid the complications of acetabular retroversion.
View details for Web of Science ID 000081178700004
View details for PubMedID 10412990
Comparative biomechanical analysis of supracondylar femur fracture fixation: Locked intramedullary nail versus 95-degree angled plate
JOURNAL OF ORTHOPAEDIC TRAUMA
1997; 11 (5): 344-350
To compare the initial stability of the genucephalic (GSH) intramedullary nail and the 95-degree condylar compression screw and side plate (DCS) for distal femur fractures.Human cadaveric biomechanical study.Twelve matched pairs of fresh frozen human cadaveric femurs.Genucephalic intramedullary nail device (Smith and Nephew Richards, Memphis, TN, U.S.A.) and the 95-degree DCS device (Synthes USA, Paoli, PA, U.S.A.) were compared. Grouped or dispersed screw constructs were tested for each fracture fixation system with progressively more severe simulated fracture patterns.Axial and torsional stiffness values.The DCS plate with the dispersed screw configuration had the greatest torsional stiffness (p < 0.0011). The GSH nail with the grouped screw configuration absorbed more energy (work) during axial loading compared with the plate constructs (p < 0.0007). There were no significant differences in axial or torsional stiffness within treatment groups for fracture patterns of increasing severity.Based on the authors' results, the selection of a GSH nail or a DCS plate should not be determined by the severity of the fracture. If a DCS plate construct is selected, the authors recommend a dispersed screw configuration, including the most proximal hole in the plate, to provide superior stiffness in torsional loading and equal stiffness in axial loading when compared with the GSH nail constructs. If a GSH nail is selected, the authors recommend a grouped screw configuration, which absorbed more energy during axial loading compared with the DCS plate constructs and the nail with the dispersed screw configuration.
View details for Web of Science ID 000071405900007
View details for PubMedID 9294798
Skin surface pressure beneath an above-the-knee cast: plaster casts compared with fiberglass casts.
journal of bone and joint surgery. American volume
1997; 79 (4): 565-569
Complications related to immobilization in a cast after an injury or an operation may be related to the materials used for the cast or to the techniques of application, or to both. To evaluate the widely held clinical opinion that the use of a fiberglass cast is dangerous and inappropriate when subsequent swelling of the extremity is anticipated, we studied the skin surface pressures that were generated beneath above-the-knee casts made with different materials and applied with different techniques. A prosthetic model of the lower extremity was designed with an expandable calf compartment to simulate swelling after an injury or an operation. With use of this model, we measured the skin surface pressure beneath a plaster-of-Paris cast, a fiberglass cast that had been applied with a standard technique, and a fiberglass cast that had been applied with a stretch-relax technique. The highest mean skin surface pressure after application of the cast (p < 0.001) and after simulated swelling of the limb (p = 0.04) was generated by the fiberglass cast that had been applied with a standard technique. The lowest mean skin surface pressure after application of the cast (p = 0.006), simulated swelling of the limb (p < 0.001), and all subsequent steps of the experimental protocol (p < 0.001) was generated by the fiberglass cast that had been applied with the stretch-relax technique. The mean skin surface pressure generated by the plaster cast and by the fiberglass cast applied with the standard technique did not return to the value before application of the cast until anterior and posterior longitudinal cuts had been made in the cast and the cast had been spread at those cuts. When the fiber-glass cast had been applied with the stretch-relax technique, the mean pressure returned to the baseline value after only an anterior longitudinal cut and spreading at that cut. The principal pitfall of the use of a fiberglass cast is related to the technique of application. When the fiberglass cast had been applied with the standard technique, it generated a mean skin surface pressure that was higher than that associated with the plaster cast and it accommodated simulated swelling poorly. When the fiberglass cast had been properly applied, with the stretch-relax technique, it generated a mean skin surface pressure that was significantly lower (p = 0.006) than that associated with the plaster cast and it better accommodated simulated swelling without the need to sacrifice the structural integrity of the cast.
View details for PubMedID 9111402
Modular tibial augmentations in total knee arthroplasty
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Proximal tibial bony deficiencies are not uncommon in primary and revision total knee arthroplasty. Modular tibial augmentations were introduced to address these deficiencies. Alterations in strain distribution as a result of medial wedge and block augmentations were evaluated for a modular total knee arthroplasty system in 6 fresh frozen anatomic specimen tibias. Full-field strain patterns were examined using photoelastic coating methods, and high strain regions were evaluated using strain gage rosette techniques. The total knee arthroplasty installations were tested in static physiologic axial and torsional load configurations. The relative effects of sequential wedge and block augmentations compared with the nonaugmented case were statistically analyzed. There were no overall statistical differences in the 3 treatments in terms of maximal (principal) strains. A secondary analysis that evaluated specific location and load pattern combinations established several minor statistical differences along with insights into the manner in which each construct loads the proximal tibia. Although metal wedge augmentation commonly is used, block augmentation seems to be an appropriate alternative from a strain distribution standpoint in cases in which the block geometry better approximates the bony defect.
View details for Web of Science ID A1996UP16900026
View details for PubMedID 8641065
IS COMPUTED-TOMOGRAPHY USEFUL AFTER SIMPLE POSTERIOR HIP DISLOCATION
JOURNAL OF ORTHOPAEDIC TRAUMA
1995; 9 (5): 388-391
Recent articles and textbooks of orthopaedic traumatology recommend routine computed tomography (CT) scans after successful reduction of simple posterior hip dislocations. This is based on the belief that CT, even in cases with concentric reductions, may identify fractures or intraarticular loose bodies not apparent on standard radiographs. This study was conducted to assess the usefulness of CT after concentric reduction of simple posterior hip dislocations. The hospital database was searched for all traumatic hip dislocations in the past 4 years. Charts and radiographs were reviewed, and only patients with simple posterior hip dislocations (no acetabular or femoral head fractures) and a concentric reduction identified on plain radiographs were included. Twenty-three patients who met these criteria and had subsequent CT scans to evaluate the hip joint were identified. CT scans confirmed the concentric reduction in all patients. Three small occult fractures were identified, and no occult intraarticular loose bodies were found. CT findings did not alter the treatment plan for any of the patients studied. In this small group of patients, CT scanning was not useful after concentric reduction by plain radiography of simple posterior hip dislocations.
View details for Web of Science ID A1995RW08100005
View details for PubMedID 8537841
LUMBAR INTERVERTEBRAL DISC TRANSFER - A CANINE STUDY
1994; 19 (16): 1826-1835
Degenerative lumbar disc disease has been implicated as a cause of low back pain. Current treatment options for low back pain involve nonphysiologic fusion of the involved segments and have variable success rates. This is an experimental study of lumbar intervertebral disc transplantation using a canine surgical model.This study evaluated the feasibility of lumbar disc transplantation and its effects on disc metabolism and morphology.Eight mature mongrel dogs underwent disc transfer surgeries, in which the L2-L3 and L4-L5 intervertebral discs, with a small segment of adjacent superior and inferior vertebral body, were removed and transposed. The transplanted disc were stabilized by plates or by a flexible cable wire construct using Songer cables (DANEK, Inc., Memphis, TN). Unrestricted activity was allowed postoperatively. At 4 months, the spines were harvested, and the transplanted discs were evaluated biochemically and histologically. Intervening nontransplanted discs served as viable controls and thrice-frozen discs served as nonviable controls. Cell viability was assessed by measuring proteoglycan synthesis and DNA content.Proteoglycan synthesis (35S uptake normalized to DNA content) was maintained in transplanted anulus fibrosus tissue, but was decreased in nucleus pulposus samples (P < 0.05). DNA content was not altered significantly in the transplanted discs. Histologic analysis of the transplanted discs showed revascularization and remodeling of the bone adjacent to the disc and preservation of the lamellar architecture of the anulus fibrosus. The transplanted nucleus pulposus samples had chondrocyte-like cells present, but the staining characteristics of the nucleus material was variable. The contour of the transplanted disc endplates was irregular in all specimens.The structure and function of autograft intervertebral discs were maintained after disc transfer surgery; the transplant discs, however, were not completely normal in either their morphology or their metabolic functioning.
View details for Web of Science ID A1994PC90300006
View details for PubMedID 7973981