Legg-Calve-Perthes Disease 2012 Update Welcome to the March 2012 Edi- a Conversation with Harry Kim, MD Tion of the POSNA Resident Review

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PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA’s Resident REVIEW Cutting Edge Orthopaedic Information Enhancing Resident Education March 2012 From the Editor, Clinical Focus Topic: Steven L. Frick, MD Legg-Calve-Perthes Disease 2012 Update Welcome to the March 2012 edi- A Conversation with Harry Kim, MD tion of the POSNA Resident Review. By: Tom McPartland, MD The educational process you are undergoing as a Legg-Calve-Perthes’ is a ‘peculiar af- resident in ortho- fliction’ of the hip in which there is paedic surgery is bony collapse of the proximal femoral undergoing sub- epiphysis after avascular necrosis. stantial changes; Despite much careful clinical research, as a program director, I am very famil- no specific mode of treatment has iar with many of them, one of which proved to be consistently effective at is the ACGME Milestones Project. I preventing long term femoral head am involved in the process of creating deformity. I spoke with Harry Kim, “milestones”, meant to assist program MD about his career as a pediatric directors in assessing achievement by orthopedic surgeon and translational Harry Kim, MD orthopaedic surgery residents of the research scientist, with a very specific knowledge, skills and attitudes neces- focus on understanding the biology When you first looked at LCP disease sary to competently address specific of Legg-Calve-Perthes’ disease and as this enigmatic problem and broke orthopaedic problems. Hopefully you the development of new treatment it down in to its component parts, have found some mentors from medi- strategies. Dr. Kim is the Director what was your initial understand- cal school and residency to help you of Research and the Director for the ing of the problem going into your in your career. One of my mentors, Center of Excellence in Hip Disorders research? What could you take for Richard Gross, is passionate about resi- at the Texas Scottish Rite Hospital in a given? dent education, and has often helped Dallas, TX. He is a recipient of the me frame and understand important Arthur Heune Memorial Award for I started to study this area (15 years issues related to residency education. Excellence and Promise in Pediatric ago) at Shriner’s Hospital in Tampa Below are some comments he shared Orthopedics, four(4) Best Basic Science and before that at Toronto Sick Kids. with me recently about measuring Paper Awards at the POSNA annual I worked with Dr. (Robert) Salter milestones in orthopaedic residents: meeting, the St. Giles Young Investi- who contributed significantly to this Here I set in writing some thoughts gator Award, and the AAOS-OREF field. When I looked at this ques- on “milestones”, or more broadly, Travelling Investigator Award, among tion, what was not clear is why the what concepts and tenets as “educa- many other honors. femoral head was deforming. This tors” we should grasp to introduce question arose because we could not our residents to the art of surgery. Dr. Kim, thank you for taking the accurately predict who would do well time today to speak with me about and who would not do well. A poor “Art” is a deliberate choice, because this problem which has perplexed outcome was defined as the femoral it reflects an alternate approach to pediatric orthopedists for decades. Continued on page 2 Continued on page 8 Clinical Focus Topic: Legg-Calve-Perthes Disease 2012 Update A Conversation with Harry Kim, MD continued from page one head deforming significantly. The Physical Therapy, splinting, and Your group has shown the promising literature suggested the problem lay adductor tenotomy have been used to effect of bisphosphonates in the healing process (resorption and maintain range of motion. (ibandronate) in preventing bone lack of anabolism). There was large Varus femoral osteotomy, Salter’s resorption in LCP. How did you knowledge gap. We had good clinical innominate osteotomy, and other select BMP-2 as the bone anabolic information but the understanding of procedures like the shelf osteoplasty agent to accelerate healing? What biology was missing. have been applied in certain groups were its promising properties? or when there is extrusion of the hip. We can’t take specimens from patients, How do these clinical practices fit We were attracted toBMP-2 for its so the information on how healing pro- into this evolving understanding of excellent osteogenic potency. It was gressed was limited in humans. That’s Perthes’ disease? readily commercially available, al- why we turned to animal models to though in an off label indication. In understand why the femoral head de- Another thing I think is important addition to its osteogenic potential, forms after losing blood supply. This is that Perthes’ (disease) is complex BMP-2 also stimulates new blood ves- gave us a clue that there was a biologic - there is this pathobiology but there sel growth, which is an attractive prop- response that was pathological. The is also an effect by the mechanical erty in avascular necrosis. BMP is very healing process contributes to the pa- environment. The femoral head is dis- potent and there is a risk for develop- thology. This may be a target area for eased and the child continues to load ment of heterotopic ossification and improvement in treatment. it. If you continue to load a femoral we have seen this in our animal model. head with total (epiphyseal) involve- It needs to be used judiciously and you (The piglet has become a well studied ment, regardless of what you do to want to use minimal dose without side model for LCP because of its similar biology, you will still get a deformed effects. In our study in JBJS 2011, BMP epiphyseal circulation and, more im- head. It takes time for the head to heal, led to bone formation, but the animals portantly, it mimics the progression and unless it is protected during that got heterotopic ossification in the hip through fragmentation and reossificia- healing phase then it is going to fail capsule in all animals. tion that occurs in humans). mechanically. So this brings up the question of One of the first things we could How does weight bearing factor delivery. Do you see any promising identify is that a lot of bone resorp- in here? technology for this agent to keep it tion would take place. And there is in the epiphysis? also not enough new bone formation. So we have studied in the experimental There is an imbalance between resorp- model the role of weight bearing in So that’s an active area of our research. tion and bone anabolism. This led to this process. We found it contributes How can we deliver (effectively) and the thought of using an anti-resorptive significantly to the deformity. What we decrease the dose to reduce compli- agent (bisphosphonate) and then later think needs to be done is the patient cations. So when we first did it, we using a bone anabolic agent (BMP-2). needs to be locally non-weight bearing pushed the drug in. Now we infuse or more specifically toe- touch weight with a pump over a twenty-minute (Dr. Kim’s group published a paper bearing with crutches, not at bedrest. period. The other thing would be to in JBJS May 2011 on combining iban- Because compliance can be difficult, use a biodegradable (delivery system) dronate and BMP-2 and it improved we probably need to add a biologic to to keep the drug contained. It will take healing and decreased deformity in accelerate the healing phase. The goal some time to figure out what will be the piglet model) would be to minimize the duration of the optimal way. fragmentation and maximize healing When I started, the first issue was and reossioficaiton so you can reduce Do you potentially see some form of understanding the deformity (and duration to 6 months or less. surgical intervention to deliver those its pathobiology). We have a better biologicals? grasp on this now. Now the target is (Perthes’ disease fragmentation phase to find ways to modulate the healing can last up to 2 years in some children I think so. So when you look at Dr. process. which affords more time for the femo- Herring’s Work and Dr. Wiig’s work ral head to deform. We are forced to from Norway, the femoral osteotomy Many articles describe principles limit kid’s activities for a long time) seems to have an effect in certain age of “containment” for the clinical groups on outcome, but the effect is treatment of Perthes’ disease. Continued on next page Clinical Focus Topic: Legg-Calve-Perthes Disease 2012 Update A Conversation with Harry Kim, MD continued from page two modest when looking at head shape in necrotic bone and these fatigue get back to playing sports. The parents (Stulberg outcome), so we can poten- points become a macrofracture. We want the child to have the full experi- tially use a biological along with femo- must consider the biology and try to ence of childhood instead of being left ral osteotomy to further improve the promote angiogenesis and speed up behind for a couple of years to have the results and to make the good results new bone formation. So the concept disease heal. For me, you definitely more consistent. That’s the (current) is similar in that we may need to make more impact (by being involved problem; we do surgery and don’t get modulate biology and also consider in research) even though it can be a the consistent result. We are succeed- mechanical treatment. slow process. I was very fortunate ing 40-60% of the time but we’d like to work with Dr. Salter, and identify to be 85-90% successful. I’m sure it’s difficult to structure a good animal model to study this your methodology so you are not condition. I had great institutional So what’s the optimal approach to trying to move too quickly on support at Tampa Shriner’s and then treating Perthes’ disease as you see something that is new and exciting, here at TSRH. it now? but really study it rigorously and make sure you are not changing too How much time do you dedicate to Optimizing the mechanical protection many variables at once. In my mind, research and to clinical patient care? while modulating and stimulating the that is one of the hardest things that healing process using biologic agents you as a basic science researcher do. I have one day per week in clinic and is the more broad approach to it. For How do you stay focused when it four days a week for research. I am last 50-60 years we’ve been focused takes years to see changes? now the director of research and get on containment- I think it works to involved in the development of stud- some degree but, a pure mechanical It’s quite difficult. When patients come ies in collaboration with other docs approach, I think, is insufficient to get in, you often wish you had a treatment at TSRH. good results on everybody. I think to you could apply that you believe will have more effective treatment, you work, but it is still in the lab. You Do you have anything else you want need to deal with the mechanical as- would not take an unnecessary risk to share with us Dr. Kim? pects of the disease but also biological with patient. It is important to make aspect. By combining both approaches sure you take cautious steps and not We are having the first International we will probably get better results. rush into clinical applications. We are Perthes’ Study Group here in Dallas starting to use biologicals in very se- March 8-9. Fifty centers are participat- How do you see the research in LCP lected patients. This is the way it needs ing. We can do a multi-center prospec- translating to adult AVN? It is a to be done in the initial phase in order tive cohort study and within 2-3 years little bit of a different problem. to determine what is the best surgical as we can get a better idea of patient Remodeling potential isn’t there. approach, best dose and application volume and potential recruitment Can we augment core decompression technique for biologicals. rate. We are thinking about doing a with biologicals? randomized clinical trial on bisphos- Do you have any advice to aspiring phonate treatment as an adjuvant or To some extent I consider our ado- pediatric orthopedists who are supplement to varus osteotomy, with lescents in that group. I see issues interested in research? blinded placebo controls. This would with poorer angiogenesis. Regard- improve significantly on previous less of what you do in young kids, Research adds to pediatric orthopedics, study designs and hopefully give us new endothelial cells and vascular being able to find ways to improve the power we need to answer some of granulation tissue migrates into the understanding of our diseases and these questions. necrotic bone; this does not occur in improve treatments. We as practitio- adolescents and adults. Core decom- ners and surgeons ask these questions We will all certainly look forward to pression and vascularized fibula are a and try to get answers. I don’t think the forthcoming data and hope for good idea because you are bringing in there are other people (basic science some new methodologies for treating new blood vessels. I think the issue is researchers) out there who understand Legg-Calve-Perthes disease in the near you have to consider the mechanical the disease and feel passionate about future. I thank you for your time and aspects. If the patient starts to weight it, because we are the ones actually your important contributions to pedi- bear too early you have too few cells treating patients. Every day when I go atric orthopedics. to detect microdamage and repair the to the clinic, I feel the urgency to try to process and you develop microcracks find the answer. That child wants to An Interview with Dr. Chad Price By: Pablo Castañeda, MD

didn’t have so many back to Orlando I had a fellowship, self inflicted injuries and people started sending me really and they seemed to do complex stuff. better than the adults did. You have had a fantastic career. Do you have any insight into the I was born and raised evolution of pediatric orthopedic in a little town in the surgery? middle of Florida, before there was air Let me start by saying that I think conditioning and there the future is very bright. Early in weren’t many roads to my career everyone did pediatric get there. It was mostly orthopedics, and the pediatric cattle and citrus, an orthopedist was the tertiary referral agricultural town with specialist who took care of the really about 80,000 people. We difficult stuff: cerebral palsy, spina did a lot of hunting and bifida, limb deficiencies. I mean the fishing, and I considered worst of the worst; but clubfeet and it a rural community hip dislocations and fractures were Chad Price, MD with patient even when I graduated taken care of by general orthopedic from high school in surgeons, so you only needed about Please tell me about your early life 1963. Then Disney came to that little one pediatric orthopedic surgeon for and whether this had any influence town in 1971, and that town is now every 500000 people. But then we on your ultimate career choice as a Orlando. So I grew up in Orlando, became the orthopedic surgeons for pediatric orthopedic surgeon. but like to think I grew up in a small everyone under about 14 years, but town and Disney just happened to us. we were still doing everything: spine, I think all those things influence you I was very fortunate to grow up in hip, foot; the procedures weren’t so in ways you don’t appreciate at the this great place and then come back complex that you couldn’t master time. I was fortunate to be exposed afterwards. You really couldn’t have them all and that was tremendously to medicine early in my life with my practiced pediatric orthopedics in fun. father being a surgeon. I knew what Orlando when I was a kid, and seeing it meant to be a doctor and even the change has been fascinating and Now it seems to me that there is back then it was pretty grueling but has turned out great. a good trend in subspecialization, it appealed to me. I didn’t know that while there is still a definite role for a I wanted to be a orthopedic surgeon I did my fellowship with Wood Lovell general pediatric orthopedic surgeon. until I finished med school. in Atlanta, which is about as far north Those of us in academic practices as I ever got in my career- I think it often don’t see how great it can be to I went to Baylor in Houston which actually snowed that year... It was have a private practice. When I was was terrific. It was one of the first unusual because it was a time when coming along you could really only schools to do integrated teaching, and most people weren’t doing formal practice pediatric orthopedics in an I was exposed to orthopedic surgery fellowships. I was supposed to go to academic setting, but now you can as well as general surgery. We got to Vietnam, but the war was winding have a successful practice and take do a lot of surgery, which was one of down, and 2% of the enlisted were care of fractures and SCFE and Perthes the most appealing aspects of it. released from their obligations. I was disease and scoliosis and do all sorts of one of the 2%, but I didn’t know that great procedures, and send the really I grew up in Central Florida and after until 6 weeks before my residency complex stuff like skeletal dysplasias my time in Texas I came back home ended. I had a wife and 2 kids and no and limb deficiencies to a big center. to do my residency at the University place to work and my plans were to There is a lot of gratification in being of Florida in Gainesville and did my go into the military. Fortunately for a community pediatric orthopedic orthopedic residency program with me, Wood Lovell took an extra fellow surgeon, but you also have an Bill Enneking. I was considering in that year and I am forever indebted opportunity to subspecialize and be a sports medicine but somehow I got to him for giving me a job in addition hip surgeon, a sports surgeon, a spine turned on by the kids because they to the great training. So when I came Continued on next page An Interview with Dr. Chad Price, continued from page four surgeon. There are a lot more choices you go and you fix something and side tends to be less attractive - you now in pediatric orthopedics and that immediately you can tell whether really want to be doing things in the is a good thing. you did a good job or not; but also operating room but clinic is really in pediatric orthopedics you get a lot only the place you go to find the What is your current practice like? of delayed gratification. So to me the cases and the patients you want to beauty of pediatric orthopedics is you operate on. Then later on you find I currently work with a 7 man group get this mix of both immediate and you can really enjoy clinic and the and there is more subspecialization delayed gratification. nonoperative aspect of taking care of within the group. One of the great patients. As a counter example, if you things about pediatric orthopedics Right now in my practice the delayed are cardiac surgeon, or even a total is that you do get to operate on the gratification is by far the biggest piece joint surgeon, you’re either in the whole body and do spine, lower for me. Having lived and practiced operating room or retired, whereas limb, upper limb, and even benign in the same place my whole career, a pediatric orthopedic surgeon can tumors. Within our group everybody it’s kind of hard to describe the really enjoy the other aspects of taking still does everything, but for some of relationship you get with someone care of patients. the more complex things like cervical who you have been taking care of spine, one person who will do that. for 30 years. They invite you to their So the opportunities to continue doing wedding, and send you e-mails what you like doing are always there. My practice over the last couple of from college, and invite you to their Now, I enjoy the intellectual challenge years has been focusing more on the graduations; and sometimes it seems and analysis of the decision-making nonoperative side of things, and I’ve like a bit of a burden at the time when process –it is much more intriguing to been seeing more scoliosis and hips you’re busy and you have a lot of stuff me; I’m in a more cognitive mode. from the nonoperative angle. That’s going on, but it gives you a chance to been a lot of fun for me. see what an impact you have had on Don’t get me wrong, the surgical peoples’ lives and how important you skills and the enjoyment of doing the I think when you’re starting out you have been to them. It is very humbling procedures were my favorite part of don’t want to restrict yourself, but that people put that much trust, my career- but in your more senior as you get older you can focus on confidence and faith in you. That part years the intellectual challenge and a more narrow target, and it can be just comes to life later in your career. I the interaction with patients and their increasingly fun because you get to certainly didn’t appreciate it as much families in clinic is very meaningful. do more and more of the things you before as I do now. We are fortunate that we can shift really want to do. At first you want to do everything but as you get older “I treasure being a doctor, and an orthopedic you want to focus on specific things. So my practice now is more academic, surgeon who takes care of kids and can make and I am taking things a little bit more a meaningful difference.” thoughtfully.

I don’t take call anymore, which is a Earlier in my career I was just thrilled gears later in our careers and take good thing, but even that has changed to be taking care of people and advantage of all that. so much, with cold trauma and taking doing these procedures which were care of things within the subspecialty so much fun to do. I thought I was Is there a secret to balancing a group. It has allowed us to improve doing a good job, but when people family life with the successful our lifestyles and our ability to take you have been taking care of start to career? care of patients. have these tremendous achievements, like becoming a PhD or many other Well I don’t think there’s any secret So I think it’s an exciting time to be a accomplishments, which they could in that - it’s about having a good pediatric orthopedic surgeon. not have done without your help, marriage or life partner. I don’t feel then it allows you perspective on why qualified to give anybody marriage What’s the most rewarding or you went into pediatric orthopedics advice, because for some people it stimulating aspect of what you in the first place. works out and for others it doesn’t. do now? Many many millions of words and The other really great thing about books have been written on the The beauty of orthopedics is it you our specialty is when you’re starting subject and I sure wouldn’t know get a lot of immediate gratification; out in your career, the non-operative Continued on page 6 An Interview with Dr. Chad Price, continued from page five much about it, other than the fact that I also really enjoy spectator sports; I broad-spectrum of humanity, and I have been extraordinarily fortunate just went to the 24 hour Rolex race while in some professions you only and our marriage has worked. last weekend in Daytona which was deal with one sector of society, as a very exciting. I enjoy any kind of physician you deal with the whole My wife Pam has been very supportive, auto racing, but mostly NASCAR spectrum- from the cocaine addicted and always understood my aspirations which you really have to experience mother who could have beaten her and goals. It’s not just when you go in in person to get the entire feel for it. baby, to the wealthy baseball player to the hospital, and you might spend It’s like being at an air show- there is or the successful businessman whose a little extra time, but it’s also about no way to appreciate the speed on the child has scoliosis or hip dysplasia. If going to meetings, spending time television- but when you’re there in you’re observant you can become a on the weekends reading, writing person, it is very impressive. very good judge of human nature. or working, and just investing time which you might otherwise use for I also enjoy going to football games The other thing we sometimes forget other purposes. It’s really important and basketball games. Both Pam and is we see people when they’re at for an orthopedic surgeon to have a I are big fans of the University of a time of personal crisis. Having a partner that understands that you’re Florida athletic teams. child ill or injured is one of the most doing something that you really stressful things to ever happen to a enjoy and that it’s not a burden. You And your career has allowed you to person, and for us it’s an everyday are, to some extent, married to your do these things? occurrence. Maybe we’ll see 20 or 30 career also. There is a potential for people like that in a day, but for them, jealousy and it’s important to have No question. I think it’s true of all it’s the most important thing, the only a spouse who is willing to share you areas of medicine that most people thing they care about; and they are with orthopedics. have the resources to do things they entrusting you to be a part of their want to do. The problem sometimes lives in this time of need. So we get So that’s my secret- that Pam has been is that we have the resources but we to see the most beautiful characters, tremendously supportive and the rest don’t always have the time. but also some of the worst of human has come pretty easy. We were high nature, and you can see people who school sweethearts and I figured if And Lynn Staheli said it best: you remain calm and become involved she could put up with me when I was want to keep your life simple and in helping with taking care, but also an adolescent she could put up with keep your overhead down, because people who get very angry and start me when I was a grouchy old man. you risk overburdening yourself with placing blame. Sometimes we don’t expenses and then you really can’t want to take care of those kinds of It obviously can’t be all about your take the time to do the things you patients, but if you learn to stand apart career- you have to find time to spend want to do. from this and observe objectively as a with your family with your kids. physician, at the end of your career When I look at most of the successful Pediatric orthopedics has allowed you develop a perspective on human senior surgeons I have known, who me to travel so much and not just big nature which very few people have seen the most happy and content, conferences, of which there are a lot the privilege to see. they have all developed some other and you can get a lot out of those. interests. I think it’s important to I treasure being a doctor, and an nurture your other interests outside I never dreamed when I went into orthopedic surgeon who takes care of medicine. medicine you can develop so many of kids and can make a meaningful friendships over the globe- you can difference. What do you like to do in your free go and visit people all over the place. time? Those avenues are open to almost Tell me about your experience anyone. If you go to a meeting, you with the International Pediatric I have always enjoyed spending time don’t have to be in an academic Orthopaedic Symposium. with my kids and my wife. Now that position- you can simply go up to Pam and I are alone, we enjoy playing someone, say maybe, from Italy, and Well, there is a long history, beginning golf. We didn’t really have time for it say I’d like to come and visit you, and with Mike Tachdjian, who was one of when the kids were younger, as we most of the time they are more than the creators of our specialty He wrote preferred to be with them. We really happy to host you for a day or two. the first major pediatric orthopaedic enjoyed doing their activities, and text and designed a review course now we enjoy our grandchildren’s One of the most fantastic things about for residents. The course went on for activities. medicine is it allows you to see the Continued on next page An Interview with Dr. Chad Price, continued from page six many years, with a number of us on the way we do, and why other people Why should a young surgeon the faculty, when he died suddenly of did things in other ways, and why considering a career in pediatric a heart attack. There was a question there was no group or organization orthopedics go into it? whether we should continue to carry like the Scoliosis Research Society out his tradition. The group got that was really looking into this. They Because you can pretty much do together and decided to stick together helped us with the financial resources whatever it is you want to do. I’ve as faculty, and for some reason I was to put together a reliable group and been fortunate enough to do what I chosen as the chairman; so I looked website. The IHDI was born- we have wanted, but it has still always around the room at the faculty he started with seven locations all over been a choice. Not everybody has had assembled and it seemed to me the world. One of the things were to do all the things I have done to we had the opportunity to upgrade a able do was design and carry out have a great career and have a great simple review course to a symposium an international multicenter cohort life and a great family. You can be a of the highest level. study, which is allowing us to have a great pediatric orthopedic surgeon great database with a patient volume in the community, attending courses There is great value in a review course, approaching 300. We should get a and practicing at the highest level but it seemed to me that if we could lot of good data out of that. Another and you don’t necessarily have to grab the greatest minds and challenge thing that the family questioned was be in academician to have a fantastic each other, it would produce a better the fact that that this condition is career. I have great respect for the result. Eventually we had enough really common, yet most people don’t community orthopedic surgeon, and faculty to have four or five leaders know about it, or have maybe heard there are a lot of people who practice on a certain subject, and let them talk about it only in dogs, so we began an at the highest possible level. You can about their most specific interest. If awareness campaign. publish and present at meetings, or you let them talk, for example, about you can just take the best possible congenital pseudarthrosis of the tibia We also knew that unfortunately care of your patients and it is just as or femur fractures, instead of having swaddling has become commonplace rewarding. just one person, we would have five in United States, with approximately or six of the leading figures discussing 82% of mothers swaddling their So what you choose to be may be amongst themselves and presenting babies. Even some of the nursery more or less visible. I have chosen a to each other as well as discussing personnel were getting that message more visible career path, but there cases. So it became more of a debating wrong, so we wanted to improve are a lot of orthopedic surgeons who society, and that’s when the chemistry public awareness and advocacy, and don’t have quite as visible a career, really kicked in and we realized that we plan to expand that have more sites and are still having a very successful everybody was learning. One of the and centers and include people who career. To me that’s the most fulfilling greatest things was increasing the have an interest in hip dysplasia. part about pediatric orthopedics- you amount of faculty, which made it can do sports, you can do spine, you more vibrant experience. We want to become bigger and more can do hip, you can be nonoperative, inclusive and do more research. If you can take call or not, you can Now IPOS is a fantastic learning you go back to Salter in 1968, he write, you can publish, you can travel opportunity- anyone from a resident, advocated prevention. As orthopedic you can go to courses, you can run a fellow or a senior faculty member surgeons we figure prevention means courses; if you don’t have a good time has a chance to learn, and it has been early detection and treatment, but in this career it’s really only because really fun to watch that grow and he felt like you can actually prevent you didn’t do what you wanted to. develop. Both the AAOS and POSNA hip dysplasia if you don’t stretch the have been very helpful with that. hips out. There is some evidence from The world is wide open to the young Klisic in Yugoslavia in the 70s, along pediatric orthopedic surgeon. You are currently involved with the the same lines, so one of the major IHDI (International Hip Dysplasia objectives of our group is to look into This interview has been a lot of fun, Institute), what has that been like? the possibility of true prevention; it’s not often you get a chance to particularly in underdeveloped talk this long about yourself to an As I said, you get exposed to all sorts regions that don’t have access to attentive audience. of people and one of my patients some of the high end technology of was the son of the comedian Larry ultrasounds. We think there could the Cable Guy, who came to me with be some ways to prevent postnatal hip dysplasia. They had a lot of good dysplasia of the hip, which to me is questions, including why we do things the big promise of the IHDI. From The Editor Learning a skill is learning to That is more work, but the choice continued from page one see the world differently. The is clear – shall we train them like skilled surgeon, for example, monkeys – with milestones, or as an emphasis on technique, which is sees something more than a someone we would ultimately be a subliminal goal of the milestone broken and bloody leg; he sees content to become our surgeon or approach. It has often been said a particular kind of break, one our family’s surgeon. That is more that one could coach a monkey, or that requires this precise surgi- difficult, and harder to quantitate, some other primate, to do a surgical technique to fix it. Likewise, but I hope our specialty’s decision cal procedure. Perhaps, but even we hear people say the successful makers will accept that challenge. the purveyors of milestones would running back has “great vision”, agree they don’t want a monkey the point guard has extraordi- -Richard H. Gross, MD, for their surgeon. Why not? The nary “court sense”. In each case Professor of Orthopaedic monkey would certainly have re- this means the person’s skill at Surgery, Medical University peatedly practiced the procedure surgery or running or passing of South Carolina to acquire the necessary technical allows them to see meaningful prowess, or in other terms, been distinctions that others without The above comments by Dr. Gross re- checked off on the milestone for their skill cannot. mind me of a favorite Einstein quote that procedure. No, what even the that I have always tried to keep in purveyors of the “milestone” want The master’s skill …………in- mind when evaluating residents and from their surgeon is the ability to volves intelligence and flexibil- faculty – observe what is there in the surgical ity rather than rote and auto- field, alert to any nuance or clue matic response. To have a skill “Much of what is counted does not that something out of the ordinary is to know what counts. count, and much of what counts can- is in play, requiring the surgeon not be counted.” to use his/her knowledge, skill, To achieve this kind of vision, and understanding to achieve the which I submit is what we want Perhaps this is what Dr. Gross is talk- desired outcome. our trainees to take with them ing about regarding “milestones” – it when they graduate and practice, certainly presents challenges to those In “All Things Shining”, one is requires more of us than counting charged with assessing educational guided through the ages, pausing cases for milestones, and I further progression and the development of to learn what was important in dif- submit that we should gladly accept competence in orthopaedic surgery ferent eras in the quest to live one’s that task, and shun the mindless residents. Let me know your thoughts life well. Suffice it to say a sense busywork of tallying numbers for about milestones, and the changes of gratitude, an admirable concept, milestones. It requires an assess- underway in your orthopaedic resi- was emphasized, even using an ment of the resident’s knowledge, dency education. excerpt from “Pulp Fiction” to il- preparation, and physical capa- lustrate. The concluding portion of bilities to determine what portion I hope you enjoy this edition of the the book examines the acquisition of the case the resident and/should POSNA Resident Review. of athletic skills, and surprisingly perform. It requires constant feed- employs some surgical metaphors back from the attending, reinforcing Steven L. Frick, MD which I found quite relevant to this what is valuable, and dissuading [email protected] discussion. Here are excerpts: the resident from using what is not. ANNOUNCEMENT: The AAP Section on Orthopaedics (SOOr) 2012 “Call for Abstracts” is now OPEN!

For details and submission guidelines visit http://aap.confex.com/aap/2012/cfp.cgi

The abstract presentation is part of the two-day SOOr Program held in conjunction with the Academy’s National Con- ference & Exhibition in New Orleans, Louisiana. The Section Program is scheduled for October 20-21 -- keep checking the SOOr web site at http://www2.aap.org/sections/ortho/ for additional details.

***** Residents, fellows, and medical students are STRONGLY encouraged to submit an abstract. Three prizes -- $1,000, $500, and $250 -- will be given for the top three abstracts presented by residents, fellows, and medical students. For background on those awards, please visit http://www2.aap.org/sections/ortho/ortho-history-rra.htm

Many thanks to the Pediatric Orthopaedic Society of North America for sponsoring the Section’s abstract awards. Focus – Pediatric Upper Extremity Challenging Cases: What Would You Do?

CASE #1 CASE #1, continued

An otherwise healthy 2 year old girl presents with a Discussion unilateral deformity of the thumb as seen in Figure 1. Historical teaching regarding congenital trigger thumb After surgery, the deformity is corrected as seen in Fig- in children recommended observation for 6 to 12 months ure 2. Choose the statement below that is true regarding before surgery, and surgery before age 4 to prevent per- this deformity. manent flexion deformity. These treatment principles have been challenged by subsequent literature. Recent studies Figure 1 have suggested that trigger thumb in children is acquired and not congenital, and that up to 70% of trigger thumbs in young children may resolve, although it may take years, with one study showing the median time to resolution of the deformity being four years. Although commonly called a trigger thumb, triggering is less common and most children present with a fixed flexion deformity of the thumb IP joint that may be mistaken for a fracture or dislocation. Surgical treatment involves simple division of the A1 pulley with excision of the pulley or shaving of any nodule in the flexor tendon; surgery is typically uncomplicated and curative, with return of full extension, even in older children. Trigger thumbs are not associated with any other health problems. Surgeons making the diagnosis can utilize this information Figure 2 to discuss the risks, benefits and alternatives of nonoperative and operative treatments.

The correct answer is D.

References Dinham JM, Meggitt BF. Trigger thumbs in children. A review of the natural history and indications for treatment in 105 patients. J Bone Joint Surg Br.1974;56:153-5.56153 1974 Rodgers WB, Waters PM. Incidence of trigger digits in newborns. J Hand Surg [Am].1994;19:364-8.19364 1994 Slakey JB, Hennrikus WL. Acquired thumb flexion contracture in children: congenital trigger thumb. J Bone Joint Surg Br. 1996;78:481-3. A. Surgery was not indicated as this deformity always resolves spontaneously B. The deformity is congenital C. An echocardiogram is indicated as a high percentage of patients with this deformity also “Create Your Own” have congenital heart defects D. A fixed flexion deformity is more common than Self-Study Exams triggering E. Corrective surgery should involve division of the Create and take self study exams of previous OITE annular pulley and debridement of the nodule in questions by picking classifications and number of the flexor tendon items. Go there now! Your Response: ___ Visit: http://www3.aaos.org/education/exams/ exam.cfm

Continued on page 10 Challenging Cases: What Would You Do? continued from page nine

CASE #2 CASE #2, continued

A 7 year old patient had elbow trauma 9 months ago. ligamentous connections between the proximal radius and His elbow flexion is limited to 110 degrees, and he lacks ulna, and thus may disrupt the normal balanced growth of 30 degrees of extension. He has 30 degrees of supination, the forearm, resulting in proximal migration of the radius and 50 degrees of pronation. Which of the following relative to the ulna at the wrist. Congenital radial head dis- statements is true? locations are typically posterolateral. Anterior translation of the radial head relative to the capitellum is not a predispos- ing condition for PLRI of the elbow. Residual cubitus varus deformity after pediatric elbow trauma has been described as a potential contributing factor to PLRI development.

The correct answer is B.

References Neck Osteotomy for Malunion of Neglected Radial Neck Frac- tures in Children: A Report of 2 Cases Ceroni, Dimitri; Campos, José; Dahl-Farhoumand, Agnes; Holveck, Jérôme; Kaelin, André Journal of Pediatric Orthopaedics. 30(7):649-654, October/Novem- ber 2010 Radial Neck Fracture Nonunion in Children. Waters, Peter M.; Stewart, Susan L. Journal of Pediatric Orthopaedics. 21(5):570-576, September/October 2001.

CASE #3 A. There is no risk of osteonecrosis of the proximal radial epiphysis with corrective osteotomy and A 9 yo boy sustains this injury. What structure can get fixation trapped in the joint during closed reduction? B. The “cam-effect” is likely contributing to his poor forearm rotation Figure 1 C. Excision of the radial head will allow full motion return with no long term issues at the wrist D. The residual deformity is congenital and likely unrelated to the traumatic event history E. Chronic problems with this deformity are likely postero-lateral rotary instability (PLRI) of the elbow Your Response: ___

Discussion Radial neck malunions are difficult problems. If the range of motion is functional (some quote 30-130 deg flexion/extension, 50 deg supination, 50 degrees pronation), then no treatment is recommended. If there is poor motion, but no pain, then the risks of surgery relative to the expected gain in motion or function may lead surgeons to avoid surgery. Surgical approaches to the proximal radius in children endanger the blood supply to the developing proximal radial epiphysis and thus carry a high risk of osteonecrosis. Translational deformities disrupt the rotational arc of the radius and this cam-effect is believed to contribute to limitations of forearm rotation. Excision of the radial head in children removes the proximal physis and some of the Continued on next page 10 Challenging Cases: What Would You Do? continued from previous page

CASE #3, continued CASE #3, continued

A. The annular ligament A. Valgus stress on elbow, pronation of forearm, B. The medial epicondyle plantar flexion of fingers C. The lateral epicondyle B. Varus stress on elbow, supination of forearm, D. The ulnar collateral ligament dorsiflexion of wrist E. The capitellum C. Varus stress on elbow, pronation of forearm, Your Response: ___ plantar flexion of fingers D. Valgus stress on elbow, supination of forearm, Discussion dorsiflexion of wrist and fingers 50% of medial epicondyle fractures occur with elbow dislo- E. Supination of the forearm and flexion of the cations. They can become incarcerated in the joint during elbow and fingers dislocation itself, or during closed reduction. Your Response: ___

The correct answer is B. Discussion Though often considered an indication for surgery, attempt References at extraction of an entrapped medial epicondyle can be Scherl, SA, ed.: Surgical Management of Pediatric Long-Bone performed with the above maneuver. Fractures, AAOS, 2009, p. 28. The correct answer is D.

What is the maneuver to attempt to remove the References entrapped structure from the elbow joint? Scherl, SA, ed.: Surgical Management of Pediatric Long-Bone Fractures, AAOS, 2009, p. 28. Figure 2

CASE #4

Which of the following is not true of the structure at the arrow?

A. It is often an incidental finding B. It can be a cause of median nerve compression C. It can be a cause of brachial artery compression D. It is an osteochondroma E. A similar structure is found in cats

Your Response: ___

Continued on page 12 11 Challenging Cases: What Would You Do? continued from page eleven

CASE #4, continued CASE #5, continued

Discussion on the extremities, the nailbed is a classic location. These This is a supracondylar process. Typically found inciden- are benign vascular lesions which respond to excision. The tally, but they can cause median nerve/brachial artery bluish blush seen under the nailbed is consistent with the compression. Osteochondroma is in the differential. Cats, vascular nature of the lesion. The absence of known trauma lemurs, and a few other mammals also have supracondylar makes a hematoma unlikely. The mri shows an enhancing processes. lesion consistent with a glomus tumor. Cases of gloman- giosarcoma, a malignant version, are rare, but tissue should The correct answer is D. be sent to pathology to confirm the diagnosis.

References The correct answer is D. Subasi, M., et al., Supracondylar Process of the Humerus, Acta Orthopædica Belgica, Vol. 68:1, 2002, p. 72-5. References Paliogiannis P, Trignano E, Trignano M. Surgical management of the glomus tumors of the fingers: a single center experience. Ann Ital Chir. 2011 Nov-Dec;82(6):465-8. CASE #5 Smalberger GJ, Suszko JW, Khachemoune A. Painful growth on right index finger. Subungual glomus tumor. Dermatol Online J. A 9 year old girl presents with a painful finger. She has 2011 Sep 15;17(9):12. noticed a bruise under the nail but does not remember Oh SD, Stephenson D, Schnall S, Fassola I, Dinh P. Malignant glomus tumor of the hand. Appl Immunohistochem any specific trauma. The pain has been gradually Mol Morphol. 2009 May;17(3):264-9. worsening and is not significant. On questioning, she noticed that it hurts more when she goes out in the cold. Xr are normal, MRI below. The most appropriate treatment would be: CASE #6 A. Drilling of the nailbed to relieve the hematoma B. Wide excision and radiation All of the following are potential complications of C. Primary amputation lateral condyle fractures except: D. Local excision A. Avascular necrosis E. Splinting for 6-8 weeks B. Nonunion Your Response: ___ C. Tardy ulnar nerve palsy D. Severe cubitus varus E. Late displacement of a nondisplaced fracture Your Response: ___

Discussion The lateral condyle of the humerus receives it’s blood supply from the posterior muscu- lature. Extensive posterior dissection may result in avascular necrosis. Possibly because of their tenuous blood supply and continu- ity with the joint and thus synovial fluid, a delay in healing or nonunion is not rare. A growth disturbance related to nonunion may result in late cubitus valgus, causing tension on the ulnar nerve and thus a tardy nerve palsy. Fractures treated nonoperatively need close monitoring, as late displacement is not Discussion uncommon. Cubitus varus is typically a This patient has a glomus tumor. Although they may exist Continued on next page 12 Challenging Cases: What Would You Do? continued from previous page

CASE #6, continued CASE #7, continued complication of supracondylar fractures, although mild cu- Discussion bitus varus may occur after lateral condyle fractures, and is This patient has multiple exostosis, an autosomal dominant considered an example of growth acceleration of the lateral condition. Radiographs are characteristic, therefore biopsy distal humerus related to fracture. is not required. Since the lesion is not symptomatic, excision is not mandatory, particularly a wide excision of both The correct answer is D. lesions. While an ulnar lengthening is occasionally recommended in severe deformity, this is usually combined with References a distal radial osteotomy, not a wrist fusion. Forming a “one Sullivan JA. Fractures of the lateral condyle of the humerus. bone forearm” is not a usual option for this condition when J Am Acad Orthop Surg. 2006 Jan;14(1):58-62. Storm SW, Williams the radial head is located. DP, Khoury J, Lubahn JD. Elbow deformities after fracture. Hand Clin. 2006 Feb;22(1):121-9 Weiss The correct answer is D. JM, Graves S, Yang S, Mendelsohn E, Kay RM, Skaggs DL. A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. References J Pediatr Orthop. 2009 Sep;29(6):602-5. Steiber J and Dormans J. Manifestations of hereditary multiple exostoses. JAAOS 2005: 13:110-120.

CASE #7 CASE #8

A 9 year old child presents with a non painful bump A 4 year old female has difficulty abducting her right on his arm. Examination reveals a fixed mass as well arm beyond 90 degrees. She was delivered via C-sec- as limited rotation (supination and pronation 40 tion after failing to progress during a very challenging degrees from neutral) with a normal neurologic exam. delivery. Physical examination demonstrated appar- Radiographs are as shown. The most appropriate initial ently normal function in both forearms and hands; she treatment is: can actively flex and extend her elbow without difficulty. Chest x-ray was recently obtained to evaluate for pneumonia. Incidental finding of cervical fusions was noted (Figure 1). The most likely cause of her limited arm motion is:

A. Klumpke Brachial Plexopathy B. Erb’s Brachial Plexopathy C. Cervical Radiculopathy D. Sprengel Deformity E. Thoracic Outlet Syndrome Your Response: ___

Discussion This child has congenitally elevated scapula otherwise noted as a Sprengel deformity. This anomaly has often been seen with children with congenital cervical fusions and other congenital abnormalities. Treatment can include observation if the cosmetic deformity is not too severe and if arm function is good. A Woodward procedure can be performed A. Biopsy of the proximal lesion to move the scapula distally and allow forward abduction B. Wide excision of proximal and distal lesions and extension. Thoracic outlet syndrome can occur acutely C. Ulnar lengthening and wrist fusion when correcting the deformity as a result of the clavicle be- D. Observation ing drawn on to the first rib. E. Synostosis of the forearm Your Response: ___ Continued on page 14 13 Challenging Cases: What Would You Do? continued from page thirteen

CASE #8, continued CASE #9, continued

Figure 1 trauma then a simple fall on the point of the elbow. A high percentage of children with posterolateral dislocations have this condition bilaterally and thus confirms the diagnosis of congenital etiology. In a congenital radial head dislocation, the radial neck is often curved and the head may be rounded in a “bullet” shape and should be left dislocated unless diagnosed very early and treated by highly experi- enced surgeons.

The correct answer is D.

References 1: Ahmad AA. Surgical correction of severe Sprengel deformity to allow greater postoperative range of shoulder abduction. J Pediatr Orthop. 2010 Sep;30(6):575-81. 2: Tsirikos AI, McMaster MJ. Congenital anomalies of the ribs The correct answer is A. and chest wall associated with congenital deformities of the spine. J Bone Joint Surg Am. 2005 Nov;87(11):2523-36. References Sachar K, Mih AD. Congenital radial head dislocations. Hand Clin. 1998 Feb;14(1):39-47. CASE #9 CASE #10

A 3 year old girl fell off her scooter and “bumped” her Having recently moved to the United States, a family arm when she fell on the point of her elbow. She was brings their 4-year-old daughter to the office concerned taken to the emergency room and was examined. She about the appearance of her right arm. They inform had slight tenderness over her olecranon and limited you that she sustained an injury last year and was treat- pronation and supination; which was not painful. ed non-operatively with long-arm casting for 4 weeks. Radiographs were obtained, the next best step in this Original images are not available. After comparing patient’s treatment is: new radiographs of her right elbow (Figure A) with her normal left elbow (Figure B), you inform them: A. Examine the other elbow clinically and radiographically A. There is most likely a growth arrest of the distal B. Obtain MRI to assess location of the radial head humeral physis and an MRI or CT scan is C. Attempt closed reduction in ED necessary to confirm the diagnosis D. Open reduction and pinning with transcapitellar B. This deformity puts her at risk for tardy ulnar pin nerve palsy E. Ligamentous Bell Tawse Reconstruction C. Based on her young age, the deformity is likely to Your Response: ___ remodel completely as she grows D. Her deformity is likely to limit her elbow Discussion extension The radiographs reveal a posteriorly dislocated radial head. E. Her deformity is likely to persist as a cosmetic The differential diagnosis favors a congenital etiology versus issue with mild functional loss post traumatic. Most radial head dislocations from trauma Your Response: ___ are anterior or lateral and are the result of more significant Continued on next page 14 Challenging Cases: What Would You Do? continued from previous page

CASE #10, continued CASE #10, continued

Figure A Figure B been noted to predispose patients to lateral condyle fractures and late posterolateral rotatory instability of the elbow.

Preferred response is E.

References Otsuka NY, Kasser JR: Supracondylar fractures of the humerus in children. J Am AcadOrthopSurg 1997;5(1):19-26. Camp J, Ishizue K, Gomez M, et al: Alteration of Baumann’s angle by humeral position: Implications for treatment of supracondylar humerus fractures. J PediatrOrthop1993;13:94-97.

CASE #11

An infant presents with the hand deformity in the figure below. Which of the following is true?

Discussion This girl sustained a supracondylar distal humerus fracture that healed in varus and extension. Although flexion type injuries can occur, greater than 90% of fractures are extension type. According to Gartland’s classification, Type I fractures are nondisplaced; Type II fractures are angulated with the posterior cortex intact; and Type III fractures are completely displaced. Because the distal humeral physis contributes only 20% of the growth of the humerus, malreduced fractures are unlikely to remodel, especially in the coronal plane. Reduction, therefore, is recommended for displaced fractures. If casting alone is used, elbow flexion of greater than 120 degrees is typically required to maintain reduction, and this position increases the risk of ischemia and compartment syndrome. Percutaneous pinning is considered a safer alternative to stabilize reduced fractures and, thus, avoid the risk of hyperflexion in a cast. Since this girl A. This is an example of preaxial polydactyly and was treated with casting alone, malunion likely occurred typically follows autosomal dominant inheritance as evidenced by the asymmetric humero-ulnar angle (angle B. The digit should be excised with suture ligature between the mid-humeral line and a line drawn down the technique at approximately one year of age ulna) and Baumann’s angle (angle created by a perpendicu- C. Excision of the extra digit carries the risk of lar to the humerus axis and a line drawn along the growth painful neuroma plate of the lateral condyle) on the AP image. Cubitus varus, D. This is an example of postaxial polydactyly which or gunstock deformity, is primarily a cosmetic deformity is more common in Caucasian females than seen after malreduced supracondylar fractures; whereas, African-American males cubitus valgus is more likely to occur after lateral condyle E. Foot polydactyly is more likely to occur with fractures and may be associated with tardy ulnar nerve preaxial hand polydactyly than postaxial palsy. Cubitus varus can have functional consequences if Your Response: ___ the hyperextension is severe and limits elbow flexion to a non-functional range (cannot get hand to mouth), and has Continued on page 16 15 Challenging Cases: What Would You Do? continued from page fifteen

CASE #11, continued CASE #12, continued

Discussion Treatment should consist of: This is an example of postaxial polydactyly, or ulnar-sided A. Pinning of the sleeve to the shirt with follow up duplication. It is more common in African-Americans than exam and Xray in 10-14 days Caucasians, males more than females. Although usually B. Observe for return of biceps function by 3 months transmitted as autosomal dominant, autosomal recessive C. MRI of the brachial plexus transmission and associated syndromes may be seen, D. Transfer to OR for closed reduction and pinning especially in white children. The duplicated digit can be E. Apply a functional brace fully developed (type A) or rudimentary and pedunculated Your Response: ___ (type B). Suture ligation can be used in the newborn nursery to remove type B digits; however, surgical excision is Discussion recommended for older children or more developed digits. This child’s Xray shows medial displacement and varus Painful neuromas can occur after either treatment. Preaxial malpositioning of the unossified distal humeral epiphysis polydactyly, or thumb duplication, is usually sporadic, more with associated soft tissue swelling. This is a displaced distal common in Asian or white children than black children, and humerus physeal separation fracture. This is an uncommon affects males more than females. birth fracture and can be easily missed or mistaken for a non-displaced fracture or brachial plexus palsy. This child Preferred response is C. was taken to the OR for an arthrogram of the elbow, closed reduction, and percutaneous pinning of the epiphyseal References fracture. Recognition of the condition may prevent com- Katz K, Linder N: Postaxial type B polydactyly treated by excision plications such as compartment syndrome. Cubitus varus in the neonatal nursery. J Pediatr Orthop 2011 Jun;31(4):448-449. is common, even with operative treatment. Watson BT, Hennrikus WL: Postaxial type-B polydactyly. J Bone Joint Surg Am 1997;79:65-68. Preferred response is D.

References CASE #12 Oh CW, Park BC, Ihn JC, Kyung HS. Fracture separation of the distal humeral epiphysis in children younger than three years old. J Pediatr Orthop. 2000 Mar-Apr;20(2):173-6. You are consulted in the nursery to evaluate a newborn who is not moving the left upper extremity after prolonged labor. The child holds the left shoulder adducted and the elbow extended with no active motion CASE #13 of these joints. There is some finger and wrist flexion and extension noted. Any attempt at ROM of the limb An 8 year old baseball pitcher complains of activity elicits crying and attempted withdrawal. related elbow pain. His radiographs demonstrate fragmentation of the entire capitellum. Which one of A plain film of the left upper extremity is shown here: the following is the most likely diagnosis?

A. Osteochondritis Dissicans B. Panner’s Disease C. Congenital radial head dislocation D. Proximal radioulnar synostosis E. Avascular Necrosis Your Response: ___

Discussion Panner’s Disease is an osteochondrosis of the capitellum. It typically occurs in children under the age of ten years who are involved in repetitive sporting activities.

The correct answer is B. 16 Technology Corner for Orthopaedic Residents ing feature of this app, in addition to the vast collection of tests and videos, By: Orrin I. Franko, MD is actually the “properties” tab: for every test, data is presented for the sensitivity, specificity, likelihood ratio, In last month’s “tech corner” I focused Campbell’s Operative accuracy and other relevant statistical on 5 free “must have apps” for ortho- Orthopaedics tests based on primary literature ref- paedic residents: AO Surgery Refer- I am happy to see that Campbell’s is erences. In addition, by selecting the ence, AO Classification, OrthoEvent, the first orthopaedic text book that primary reference the user is directed Epocrates, and Google Translate. At has partially transitioned to the digital to the full literature source with full the time of writing, there were about era. I say “partially” because this app is abstract text. This is a feature that I 74 orthopaedic apps available for iPad not the complete 4-volume text, rather have not seen replicated by any other and Android, yet in the past 6 months it includes “core techniques;” brief orthopaedic material. The descrip- the number has expanded to over 200! summaries of 242 common surgical tions and videos are clear and accurate, In this issue, I will focus on 5 apps and bedside procedures accompanied from my review. This app is incredibly that offer some of the greatest value by images and videos. In addition valuable to a resident learning the to residents in the clinical arena. Since to the many brief entries, some topics plethora of specialized orthopaedic the publication of the last POSNA are reviewed more thoroughly with tests and maneuvers. Resident Review, I have launched a 20-30 unique images and videos up website dedicated to reviewing or- to 15-20 minutes in length that dem- Availability: iPhone, iPad, Android thopaedic apps: www.TopOrthoApps. onstrate how to perform full surgical Strengths: Comprehensive list, videos com. For those interested in learning procedures, such as femoral nailing, included, statistical properties with more about various apps for your ACL reconstruction, SLAP repair, ro- references mobile device, please visit the site for tator cuff repair, chevron osteotomy, Limitations: Cost, additional $7.99 for reviews and recommendations. compartment syndrome fasciotomy, downloadable videos shoulder hemiarthroplasty, and carpal Cost: $39.99 BoneFeed tunnel release. The app has a very This app is part of a family of RSS- good search feature that scans all Simple Goniometer reader applications for orthopaedic- topic titles and text within the app. Why guess when you can measure? related publications. The user can Although considered an expensive app This app is one of a series of goniom- customize which feeds are presented, at $100, compare this to list price of eters developed for the iPhone and including JBJS-Am, JBJS-Br, CORR, nearly $800 for the 4-volume print ver- uses the phone’s internal accelerom- JHS-Am, Spine, JPO, and many more. sion. I would encourage any residents eter to mimic a goniometer for clinical The feeds allow the user to review considering this purchase to review the measurements. I find it most useful for all current abstracts, view the full topics in the app to ensure they are not objectively quantifying pre- and post- text article directly from the journal disappointed with the limited available operative total knee arthroplasty range website (if you have online access), information. of motion. The results are accurate post comments, or share the article via and precise, and correlate well with Twitter, Facebook, or email. Overall, Availability: iPhone standard goniometric measurements. this app is a simple and intuitive way Strengths: familiar surgical reference, The app only has three functions: set, for orthopaedic residents to keep up- 242 procedures, images and videos hold, and reset and is simple to use. to-date with the latest publications included Although accuracy depends on the during periods of “micro-boredom” Limitations: not comparable to full calibration of your device, the app does and to identify articles they may want text reference, expensive what it says and allows for precise and to read at a later time. Cost: $100 objective measurements when a standard goniometer is unavailable. Availability: iPhone, Android CORE – Strengths: scan abstracts from all Availability: iPhone major orthopaedic journals Clinical Orthopedic Exam CORE has set the standard for a clini- Strengths: quick and objective range of Limitations: no full-text availability cal exam app. Divided by body part, motion measurements Cost: Free (iPhone) or body region, alphabetical, favorites, or Limitations: not ideal for small joints $1.99 (Android) search – the app contains a database of of the hand or foot nearly 250 clinical tests which includes Cost: $0.99 a purpose, instructions, video demo, and test properties. The most strik- Continued on page 18 17 Technology Corner for IPOS 2011 Review Orthopaedic Residents I would not hesitate to recommend IPOS continued from previous page to any of my colleagues, whether they The International Pediatric Orthopae- are interested in peds ortho or not. The dic Symposium (IPOS) was held for experience provides an incomparable Ortho Traumapedia the eighth time in Orlando this past method of learning up-to-date content This app is the ideal complement to December. Once again, attendance in the field of pediatric orthopaedics, any student, resident, fellow, or at- increased to set a new record. This alongside your resident peer, through tending taking general orthopaedic past year there were 341 attendees, expert attendings. trauma call. The app has a simple and and 68 faculty. There were 12 didactic intuitive user interface separated into sessions, and 47 breakout sessions, Jason E. Jagodzinski, MD either dislocations or fractures and with many again having an emphasis PGY-3 Resident would be familiar to any resident who on surgical skills and hands-on labs. Loyola University has used a popular fracture reference IPOS is designed to be an interactive Dept of Orthopaedic Surgery handbook. Each topic is divided into symposium that provides educa- Chicago, IL four sub-topics: facts, image, classify, tional experiences for learners of all and treat. With an easy-to-read bullet levels- from the novice to the prac- format, the user can quickly glean the ticing expert. Resident participation most critical facts about a particular in IPOS is key to both the success of I would like to thank you for the oppor- fracture, answer common “pimp” the meeting and the future success of tunity to attend this year’s IPOS on a questions, understand how to read pediatric orthopaedics, as during the scholarship. I was very pleased from the images with relevant annotations, and meeting residents may get interested moment I read about the mentor/men- review various classification systems in pediatric orthopaedics as a career tee program. As a foreigner, and as a for a particular injury. Overall, the choice. POSNA has established a resi- resident, for me it was very important material appears to be consistent with dent mentoring program for residents to receive advice and guidance at the most other orthopaedic trauma texts, attending the IPOS meeting to pair symposium, as well as help in further although no references are provided. residents with pediatric orthopaedic decisions regarding my fellowship or faculty members. Following are some later on my practice. Availability: iPhone comments from a few residents who Strengths: complete fracture guide attended IPOS 2011. My mentor was Dr. Schwend, and I had with image annotations and classifi- the chance to speak with him and share cation data IPOS 2011 was highly recommended by my impressions. We talked about my Limitations: bullet-point format with an attending and a senior colleague at my future goals and plans and the best ways limited information program. They foretold a second-to-none to accomplish them. He was very kind, Cost: $9.99 mix of education, professional connections and introduced me to other members of and fun. Unlike any course I’ve attended the faculty as well. before, IPOS blended a curriculum appropriate for all attendees. As a resident I was ©Loews Hotel This has been one of the academic high- able to learn from every session, meanwhile Save the Date lights of my residency; and the chance to I was sitting next to practicing orthopods listen to the people whose names I recog- whom I assume were learning equally as nized from the literature, talking about much. Amongst the most beneficial as- the things they are obviously passionate pects of the course was the opportunity for about was fascinating. I really enjoyed connecting with other interested residents, the smaller sessions and the breakouts, current fellows and active attendings; all especially the hands-on workshops as they of whom are influencing the direction of really gave me the chance to get close to pediatric orthopaedics. By participating people who were all more than willing to in the symposium I therefore had the feel- share their experience and teach. ing I was at the cutting edge of pediatric 2012 IPOS orthopaedic care. An additional unique Thank you for caring about the residents opportunity IPOS provides is the faculty Nov. 28 - Dec. 1, 2012 and their needs. mentorship program. I was paired with a course faculty member who subsequently Loews Royal Pacific Resort Ana María Serrano MD developed a personal level of comfort such PGY 4 Orthopaedic resident Universal Studios, that I could sit alongside and discuss Orlando, Florida the intricacies of the field with a leading ABC Medical Center member of the pediatric orthopaedic com- Mexico City munity. Continued on page 19 18 IPOS 2011 Review learner participation and served more as and what to look for in a fellowship and continued from page eighteen an interactive seminar than a lecture. I job, balancing clinical time and research found this environment highly conducive during a career, the future of pediatric This year I attended the IPOS meeting as a to learning. The breakout sessions allowed orthopaedics, and addressed issues they third year resident. I went to the meeting for some hands-on learning with implants encountered early in their careers. I left with an interest in pediatric orthopaedics, and surgical techniques, led by well the session feeling I had gained an inside hoping that it would be an educational respected pediatric orthopedists. The dis- track regarding how best to succeed in experience and could help me guide me cussion groups were relevant, interesting, fellowship and beyond, whether it’s as a to decide if pediatric orthopaedics was and allowed me to learn how the experts pediatric orthopaedist or something else. the subspecialty for me. The interactive approach particular clinical scenarios. The conference also arranged a mentorship educational conference exceeded all of my The pediatric orthopaedic community is program for residents, aimed at promoting expectations. This educational conference smaller, allowing for friendly collabora a career in pediatric orthopaedics. In this was the fourth orthopaedic conference that tion and “bouncing” thoughts off one program, interested residents were paired I have attended during residency and it another. This collaboration was clearly with a faculty member for a breakfast one was by far the best. The format is a mix evident during the “tough” clinical case morning. This was a great opportunity of didactic lectures, panel discussions, discussions. The faculty consisted not only for a “one-on-one” question and answer small group surgical technique labs, and of the “giants” of pediatric orthopaedics, session, and even more so to gain a mentor discussion groups. This combination whose articles and books I have read, but within the field. created an interactive environment for also some new and upcoming leaders. The learning and meeting some of the leaders in faculty were approachable and engaging In summary, IPOS was unique and very the field of pediatric orthopaedic surgery. during breakout sessions, but also during informative for learning about the treat- Each lecture placed a heavy emphasis on breaks throughout the conference. ment of pediatric orthopaedic conditions. I left IPOS with an increased interest in a Another great part of the meeting was pediatric orthopaedic career, and I would 2012 Editorial Board the emphasis placed on new orthopaedist encourage all residents to attend. anticipating a possible career in pediat- Pablo Castaneda, MD Mexico City, Mexico rics. One breakout session was totally F. Keith Gettys, MD dedicated to educate on what a career in PGY-3 Resident Craig Eberson, MD pediatric orthopaedics would be like. The Carolinas Medical Center Providence, RI discussion panel provided advice on how Charlotte, NC Ron El-Hawary, MD Halifax, NS, Canada John (Jack) Flynn, MD 2012 POSNA Philadelphia, PA ONE Day Course Chip Iwinski, MD Lexington, KY Adolescent Hip Disorders May 16, 2012 Thomas McPartland, MD East Brunswick, NJ Hyatt Regency Todd Milbrandt, MD Denver, Colorado Lexington, KY Kenneth Noonan, MD Madison, WI 2012 POSNA Kristan Pierz, MD Annual Meeting Hartford, CT May 16 - 19, 2012 Susan Scherl, MD Hyatt Regency Omaha, NE Denver, Colorado Brian Smith, MD New Haven, CT Visit the POSNA website at EDITOR: Steven L. Frick, MD Charlotte, NC www.posna.org for details.

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