Mubarak Wenger Chambers Newton Wallace Pring

Connections2009

Message from the Director

Dennis R. Wenger, M.D.

IntroductionSpringtime brings the annualDavid Sutherland VisitingProfessorship and reminds us thatit is time to provide an update onthe activities of the RadyChildren’s Hospital – University ofCalifornia San Diego orthopedicprogram.

The aim of this newsletter is tokeep former fellows, residents,friends and colleagues updated onthe clinical activities of the depart-ment as well as on the future plansfor our educational and researchprogram.

Our mission is to provide worldclass patient care, education and

research for children’s orthopedicconditions. The research is focusedon clinical and biomechanicalissues that allow early applicationto patient problems. In addition toorthopedic fellows, residents andmedical students, we also educatenurse practitioners and physicianassistants as they enter our pro-gram, allowing us to have a largeand comprehensive clinical careprogram.

Recognition Recent notification that the U.S.News and World Report 2009Healthcare issue has ranked ourorthopedic program as 4th in theU.S. confirms that our energy,strategy, and hard work are widelyrecognized and appreciated (seearticle in this issue).

Educational ActivitiesThis has been an extremely suc-cessful year with continued growthin both our clinical and researchactivities. We are experiencing anincreasing number of applicants

for fellowships throughout theUnited States and continue toattract fellows of the highest quali-ty. A continued flow of outstandingfellows allows maximal functionof our clinical program as well asallowing us to prepare pediatricorthopedic surgeons for the futurewho will be practicing throughoutNorth America and the world.

Four current fellows will completetheir fellowship year at the end ofJuly, 2009, with four new fellowsbeginning on August 1, 2009 (fea-tured in this newsletter).

The fellowship application processwill become somewhat moreorganized in 2010 since thePediatric Orthopedic Society ofNorth America (along with the SanFrancisco match program – a pri-vate enterprise) have reached anagreement to allow all fellowshipcandidates to apply through amatching program.

A Newsletter from the Pediatric OrthopedicTraining Program

Rady Children’s Hospital and University of California – San Diego

Issue 5 – 2009

Yaszay Edmonds

Thus interviews will not begin until January 1, 2010and will be completed by March 31, 2010, with thematch completed in April. It is hoped that this processwill make the selection of fellows a more standardizedprocess.

Our residency continues to have high quality residentsfrom UCSD, the San Diego Naval Medical Center, andthe Wilford Hall Air Force program (San Antonio).This allows us to be exposed to the best orthopedicresidents in North America and we greatly enjoywatching them mature and develop. We are happy tofind each year that one or more chose to pursue acareer in children’s orthopedics.

Our international fellowship program continues, and atall times we have two international fellows studyingboth scoliosis as well as children’s orthopedics.

Our nurse practitioner/physician assistant program hasenlarged and we now have nine NP/PA’s in our pro-gram, allowing us to provide both urgent and electiveorthopedic care for the children in a population area ofabout 4.5 million people. Our 62,000 annual patientcare visits (clinics, admissions) attests to this effort.

We look forward to the return of Lisa Crabb, RN, todirect our clinics and to coordinate the fellows and res-idents. After a period of “time-off” she is ready to con-tinue her leadership in August.

Staff AdditionsAfter the completion of his fellowship in July 2008,one of our fellows, Dr. Eric Edmonds, who had beenan orthopeidc resident in the Carolinas program inCharlotte (but a native of North County, San Diego)decided to do additional sports medicine training andthen to join our fulltime faculty as our eighth staffmember. His focus is on sports medicine and he hasalready developed a comprehensive practice with alarge surgical volume as well as having started multi-ple research projects.

In addition, on July 1, 2009, we will be joined by Dr.Harish Hosalkar, from the University of Pennsylvaniaand Children’s Hospital of Philadelphia. His specialinterests include complex hip disorders in childhoodas well as orthopedic trauma.

Research LeadershipOur research program continues to be highly produc-tive, resulting in many publications as well as multiplepresentations at the Scoliosis Research Society,POSNA, and many other venues. Peter Newton pro-vides the intellectual leadership and Tracey Bastromthe administrative guidance for the program. We alsohave the pleasure of bringing on a new PhD bioengi-neer, Dr. Diana Glaser, who will begin August 1, 2009.This assures continuation of our very productiveresearch program.

Hospital NewsRady Children’s Hospital continues to be fully utilizedand we are moving into the final year of constructionon the new $350 million patient care building. Allpatient care beds will be moved into this area, likely inlate 2010.

National and International ActivitiesOur staff continue to be active on a national and inter-national basis. Each of the more senior staff memberslectures throughout North America and the world, andseveral of our members have been in leadership posi-tions, serving on the Board of Directors of thePediatric Orthopedic Society of North America, theScoliosis Research Society and the AmericanAcademy for Cerebral Palsy and DevelopmentalMedicine.

SummaryThe orthopedic education and research program atRady Children’s Hospital San Diego continues it’snational and international prominence. The addition ofnew orthopedic staff, a new PhD bioengineer as wellas the completion of a new children’s hospital buildingshould enhance our productivity.

We appreciate the support of Rady Children’s Hospitaladministration, our growing alumni group and all whoare interested in our mission.

Dennis R. Wenger, M.D.

Director, Pediatric Orthopedic Training ProgramChildren’s Hospital – San Diego

Clinical Professor of Orthopedic Surgery UCSD

2

3

New Staff

Eric W. Edmonds, M.D.

Eric Edmonds, M.D., joined our practice in August of2008 upon completion of his pediatric orthopedic fel-lowship with us. He was a native of Fresno, California,and attended Johns Hopkins for his undergraduateeducation. He returned to California for medicalschool at UC Davis, followed by his orthopedic resi-dency at the Carolinas Medical Center in Charlotte,North Carolina. Eric has had a life-long commitmentto sports and athletics, which led him to Children’sspecialists where he is the Chief of Sports Medicine.

Eric’s current patient population consists of 60%sports medicine, which includes shoulder, knee, ankle,

Edmonds family

wrist and elbow joint injuries sustained through sportsor play. Sports medicine patients tend to be adoles-cents between the ages 14-19, but can include childrenas young as six years. Depending on the season, theseathletes can be actively competing in various sportsincluding swimming, volleyball, tennis, soccer andfootball.

Eric plans to further develop the Children’s Specialistssports medicine program and substantially expand thematerials and information that are available to patientsand physicians.

Tamara Zagustin, M.D.Rehabilitation and Physiatry

Dr. Zagustin joined Children’s Specialists of SanDiego and Rady Children’s Hospital in January,2009, as the new division director for

Rehabilitation Medicine and Physiatry. She completed a fellow-ship in physical medicine at the Denver Children’s Hospital andcomes to us with a plan of expanding a comprehensive team-based approach to children’s physiatry and rehabilitation medi-cine here at Rady Children’s Hospital. She is already runningmultiple clinics, including the General Multidisciplinary RehabClinic as well as her very popular Spasticity Clinic, in which sheworks closely with both Dr. Chambers of orthopedics and Dr.Friedman of neurology. Dr. Zagustin is also involved in theChronic Pain Clinic and has introduced canine therapy to assistrehab patients during their therapysessions in the inpatient unit. Theorthopedic department is delightedto have Dr. Zagustin as a profes-sional colleague.

4

National Ranking of Orthopedic Program

– Rady Children’s Hospital – San Diego

August, 2009

We just learned that the August 2009 U.S. News andWorld Report Healthcare Issue, which evaluates chil-dren’s hospitals, has ranked our orthopedic departmentas #4 in the United States. The evaluation system wasbased on an intensive scoring system and evaluation ofall aspects of pediatric orthopedic programs, rangingfrom infection prevention index to quality of nursing,patient and family services, number of specializedclinics, and both inpatient and outpatient surgical vol-ume. Of particular notewere the figures related tooverall patient volume,(total visits to the hospitalin a year’s time – clinics,also admissions) wherethe Children’s HospitalSan Diego’s number of62,546 was the greatest inthe U.S.

This high ranking reflects both the quality of clinicalcare that we give, but in particular, our academiceffort. We are able to draw outstanding faculty into ourprogram because of their desire to be involved in aresearch and development mission to not only care forpatients but in addition, provide new treatment meth-ods for children’s orthopedic problems. These staffalso enjoy the comeraderie and energy of our teachingprogram.

Our overall success is the result of our unique academ-ic/private care model, which with internal manage-ment reflects a nimble, agile, “just in time” manage-ment approach that is a national model.

OR excellence

Teaching

Clinical patient care

Many people can be thanked for this rating, rangingfrom hospital administration to our tremendously sup-portive anesthesia, nursing, intensive care, and radiol-ogy departments as well as other services which sup-port our mission.

Having outstanding residentsfrom multiple programs, aswell as having an internation-ally ranked fellowship pro-gram also helps us. Seeingour large patient volumerequires a tremendous effortand unbelievable administra-tive organization as well aswork by our physician assis-tant/nurse practitioner group.Of special note is our office

Biomechanics laboratory

5

New Orthopedic Staff Surgeon – July 2009

We are pleased to announce that beginning July 1, 2009, we will have a new orthopedicstaff-faculty member, who comes to us from the University of Pennsylvania. Dr. HarishHosalkar, who is a native of India, completed a residency in India followed by a fellow-ship in children’s orthopedics at the Great Ormond Street Hospital for Children inLondon. He has just completed an additional residency at the University of Pennsylvania,where he graduated with honors, including being awarded the Outstanding SeniorResident in a Teaching Capacity, as voted by the junior residents.

During his last year at the Penn program he spent three months doing the A-O Muller hip preservation fel-lowship in Berne, Switzerland. Dr. Hosalkar has a tremendous research interest and has already published 88papers. His special interest in our program will be to help us expand our hip treatment program, includingresearch related to many hip disorders in childhood.

We look forward to the arrival of Dr. Hosalkar and his wife Hetal, a pediatric anesthesiologist, as well as theirson Hriday. The addition of Dr. Hosalkar should allow us to continue our important record as an internation-al contributor to pediatric orthopedic research, presentation and publication effort.

Applied research

Lab research applied to clinical problems

staff, which has been selected over many years andrewarded for their outstanding work ethic and dedica-tion to our mission.

We are pleased with this ranking and will continue oureffort to improve in every area of patient care, teach-ing and research.

6

2008-2009 Fellows – Children’s Hospital-San Diego

Humberto Guzman, M.D.

Humberto, born and raised in San Juan, Puerto Rico,completed his undergraduate and medical school edu-cation at the University of Puerto Rico, followed byorthopedic residency at the same institution. Researchinterests include scoliosis as well as evaluation of onevs. two tension band plates (8-plates) in the treatmentof genu valgum.

Following his fellowship Dr. Guzman will be joiningthe academic faculty at the University of Puerto RicoDepartment of Orthopedics.

Meghan N. Imrie, M.D.

Meghan, a natvie of San Jose, California, earned herundergraduate degree in chemistry at Yale Universityfollowed by medical school at UCSD (where we cameto know her during her clerkship at Children’sHospital). She then took her orthopedic residency atStanford University. Research interests include a studyof hip dysplasia in breech babies (“best paper” candi-date POSNA – May, 2009) and scoliosis.

Dr. Imrie will return to Stanford University as a staffmember in the children’s orthopedic division of theLucille Packard Children’s Hospital.

Enbo Wang, M.D.

Dr. Wang will be completing a one year international pediatric ortho-pedic fellowship in September, 2009. He came to us from the ChinaMedical University in Shengyang, Liaoning Province and has com-pleted a research project on radial head dislocation. He also was aco-author on a scoliosis research project evaluating anterior plusposterior approaches to the spine for scoliosis correction.

Dr. Wang will return to Shengyang were he will be on the full-timeacademic faculty (children’s orthopedics).

7

2008-2009 Fellows – Children’s Hospital-San Diego

Abigail K. Lynn, M.D.

A native of Williamsport, Pennsylvania, Abbyreceived her B.S. from Lehigh University inBethlehem, PA, and her medical degree from PennState University College of Medicine. She took herorthopedic residency at Emory University in Atlantabefore joining us in San Diego for her fellowship.Research interests include a study in which she com-pared the value of arthrogram and exam under anes-thesia versus MRI to determine initial head shape andcontainability in Perthes disease.

Dr. Lynn has accepted a pediatric orthopedic facultyposition at Mt. Sinai Medical Center in New York Cityand is excited to begin this new phase of her career.

Alison J. Rozansky, M.D.

Ali grew up in San Diego and went to UCLA for herundergraduate education. She then attended LomaLinda University School of Public Health where sheearned a Masters degree, and then headed to the mid-west (Chicago Medical School) for her medical educa-tion. Ali’s orthopedic residency was taken at the AkronGeneral Medical Center (where prior fellow MarkAdamczyk is on staff). Research interests include adetailed study categorizing talo-calcaneal tarsal coali-tions.

Dr. Rozansky is looking forward to practicing inSouthern California and has joined a private children’sorthopedic group in the San Fernando Valley (LosAngeles area).

Jun Takahashi, M.D., Ph.D.

Dr. Takahashi completed his six-month spine fellowship in early2009. During his fellowship he completed a scoliosis research proj-ect evaluating selective thoracic fusion in adolescent patients.

He has returned to Shinshu University School of Medicine inNagano, Japan, where he is busy applying the principles and tech-niques he learned from Dr. Newton here in San Diego.

8

Arriving Fellows – 2009-2010

Robert Cho, M.D.

Drexel/Hahnemann, Philadelphia

Raymond Liu, M.D.

Case Western Reserve, Cleveland

Takashi Ono, M.D.

Tokyo, Japan (International Fellow)

George Gantsoudes, M.D.

Mt. Sinai School of Medicine, NY

Robert Lark, M.D.

Duke University, Durham

Luis Moraleda Novo, M.D.

Madrid, Spain(International Fellow)

Future Fellows (2010-2011 Academic Year)

Eric Eisner, M.D.University of Texas Southwestern

Ryan Ilgenfritz, M.D.University of Iowa

Nirav Pandya, M.D.University of Pennsylvania

Hilton Gottschalk, M.D.University of Texas Southwestern

9

The Orthopedic Biomechanics Research Center(OBRC) at Rady Children's Hospital-San Diego wasfounded in November of 1998 with an initial researchfocus towards adolescent idiopathic scoliosis.Adolescent spinal deformity remains the major focusof the facility for evaluating varying types of materialsand dimensions for spinal fusion, while also analyzingpotential fusionless scoliosis correction constructs.However, significant efforts have also been madetoward understanding the biomechanical effects ofvarious surgical techniques for stabilizing adolescentfractures of the humerus, femur and tibia, as well asexploring the biomechanical effects of pediatric hipdeformity.

The OBRC retains a close collaborative research effortwith local institutions such as the Department ofOrthopedic Surgery at the University of Califomia SanDiego and the US Naval Medical Center. Spinalresearch in the areas of adult deformity, spinal traumaand vertebroplasty/kyphoplasty comprise the largestcomponent to this collaboration. However, biome-chanical research is also being conducted to evaluatenovel devices and materials for sports medicine appli-cations such as ACL repair and femoral fracture fixa-tion techniques. Research has also been established inthe area of foot and ankle orthopedics to evaluatemobility associated with surgical techniques used tocorrect bunions and bunionettes.

These cumulative research efforts have been accom-plished by teaming orthopedic surgeons and biomed-ical engineers with orthopedic residents and fellows.In addition, the OBRC maintains a strong teachingcomponent as part of its diverse skill set.Undergraduate interns and medical students, as well as orthopedic residents and fellows, are directly involvedin designing and developing research projects. Thismulti-layered approach has yielded significant publi-cation success with manuscripts appearing in Spine,Journal of Pediatric Orthopaedics, ClinicalOrthopaedics and Related Research, American Journal

of Sports Medicine, Journal of Shoulder and ElbowSurgery, Medicine and Science in Sports and Exercise,Journal of Foot and Ankle Surgery, Arthroscopy andthe Journal of Applied Biomechanics.

The future is bright for the OBRC as it establishesitself as an internationally recognized academic center that develops innovative ideas for the treatment oforthopedic disorders in childhood and young adults.

Orthopedic Biomechanics Research Center Arnel Aguinaldo, MA, ATC

Director, Center for Human Performance &Orthopedic Biomechanics Research Center

New Director of the Orthopedic BiomechanicsLaboratory – Summer - 2009

Diana Glaser, Ph.D., who has just completed herPh.D. at the University of Tennessee inBiomedical Engineering, will join the Children’sHospital orthopedic research team as the Directorof the Biomechanics Laboratory beginning August1, 2009. In addition to her Ph.D. Dr. Glaser hashad extensive experience in industrial develop-ment project management and university research.Originally from Germany, she is now a permanentU.S. resident who in addition to her biomedicalskills, is fluent in writing, reading and communi-cating in not only English, but also German andBulgarian. Dr. Glaser has expertise in 3-D model-ing as well as motion analysis and also has signif-icant expertise in modeling research aspects oftotal hip arthroplasty as well as other hip condi-tions.

We look forward to what will be an ideal collabo-ration between orthopedics and biomedical engi-neering and biomechanics research.

10

Our team had a very productive year, with 26 publica-tions in peer reviewed journals. Our 2007-2008 fel-lows finished off an extremely successful year, withmultiple 2008 POSNA meeting presentations.

Eric Edmonds assisted with multiple projects, includ-ing the evaluation of outcomes of surgical interventionfor anterolateral ankle impingement in adolescents(with Dr. Chambers). He also worked with Dr.Chambers to complete a study on extra-articulardrilling for osteochondritis dissecans of the patella.

Patrick Henderson started his year off working withDr. Wenger and Dr. Mubarak to evaluate their series ofpatients who underwent ligamentum teres mainte-nance and transfer in open reduction for hip disloca-tion. This work was presented at POSNA in 2008 andwas published in the June 2008 issue of the Journal ofChildren’s Orthopedics.

John Schlechter initially focused his energy on a proj-ect with Dr. Chambers, evaluating the outcome of dis-tal rectus femoris transfer in cerebral palsy patients

(using data from the gait lab). This project was pre-sented as a poster at POSNA in 2008. Subsequently, heworked closely with Dr. Newton and Vid Upasani, MDon two spine projects – one evaluating the predictorsof curve add on below a spinal fusion (presented at the2008 SRS meeting and the 2009 POSNA meeting) andthe other an analysis of upper instrumented vertebraand pulmonary function.

Vineeta Swaroop completed a comprehensive reviewof our DDH patients which was presented at POSNAin 2008 and is in the April/May 2009 issue of JPO.Subsequently, Vineeta helped Dr. Mubarak write uphis series of talonavicular fusions for dorsal subluxa-tions in clubfoot, which was presented in Boston atPOSNA (2009) and recently published.

We have four very hard working fellows this year.They did an amazing job at our Visiting Professor pro-gram and three projects (two podium, one poster –similar to the 08-09 year) were presented at the 2009POSNA meeting in Boston. I look forward to detailingtheir efforts in next years newsletter

As usual, our team is growing! We have a great groupof people, and without them abstracts could never beready for submission during the first three months offellowship.

One of our research associates, Vanessa Scott, wasaccepted to medical school and will be leaving us inJuly to start her first year at Albert Einstein in NewYork. She was instrumental in getting two of our fel-lows’ projects completed, plus has helped Dr. Yaszaywith a study on scoliosis in cerebral palsy patients.While we will miss her here, we wish Vanessa the bestfor her career in medicine.

Notes from the Research Team

Tracy Bastrom, MA – Orthopedic Research Program Manager

Vanessa Scott, Valerie Ugrinow, Molly Moor, Eric Varley, DOOrthopedic Research Team

11

Lena Sefton Clark Endowed Fellowship in Pediatric Orthopedics

The legacy of Lena Sefton Clark is reaching farbeyond the century mark.

Mrs. Clark built a strong foundation for our hospitalphilanthropy through the annual Charity Ball, now acentury old. In 2007 her family created the LenaSefton Clark Endowed Fellowship in PediatricOrthopedics to keep her ideals alive.

The endowment creates a perpetual source of fundingto support education, training and research for genera-tions of physicians to come – and the countless chil-dren they will care for. That generational reach is espe-cially true for this year’s fellowship awardee, Dr.Meghan N. Imrie.

Dr. Imrie, a Bay area native, had her medical educa-tion at the University of California-San Diego Medical

School and then her orthopedic residency at StanfordUniversity, following her father and grandfather intothe field of orthopedics.

Passionate about medicine, Dr. Imrie worked her wayup the hospital hierarchy by starting as an orderlymopping floors and transporting patients. That was inbetween training as a competitive gymnast, a sport shecontinued to compete in while completing her under-graduate degree at Yale.

Dr. Imrie’s research includes investigation of dysplasiain breech birth babies and ACL reconstruction in ado-lescents. More importantly, Dr. Imrie’s work ethic andfaultless attention to detail, not only in patient care butin preparing for conferences, exemplifies the idealpediatric orthopedic fellow.

Dr. Imrie accepting the Lena Sefton Clark symbolic “white coat” from Kathleen Sellick, CEO of RCHSD.

12

We currently have eight (soon to be nine) orthopedicstaff in the Rady Children’s Hospital-University ofCalifornia San Diego program. In a broad sense ourstaff are divided into three categories -- beginning withthe senior staff (Mubarak and Wenger) whose careersand reputations are attached to the development of theprogram. Our future is based on a second “mid-career”segment of our orthopedic teaching staff (broadlydefined as having 10-15 years of practice, teachingand research experience).

This group is followed (and energized by) a dynamicgroup of younger staff who are beginning their pedi-atric orthopedic careers. This newsletter segmentdescribes the incredibly busy lives of two of our “mid-career” staff.

Dr. Henry G. (Hank) Chambers

Hank was born in Colorado, grad-uating from the University ofColorado (Boulder) followed bymedical school at Tulane (NewOrleans) and residency in theBrooke Army Hospital program (San Antonio) wherehe received the Commander’s Award for OutstandingResearch. He then came to Children’s Hospital SanDiego for his fellowship, partially because of his deeppersonal interest in cerebral palsy and motion analysiswhere he was greatly influenced by Dr. DavidSutherland, founder of our Motion AnalysisLaboratory. After a short period of staff experienceback in San Antonio, we recruited Hank to San Diegowhere he then assumed the directorship of our MotionAnalysis Laboratory upon Dr. Sutherland’s retirement.

Hank brings an immense variety of skills to his currentposition on our staff. In addition to serving as Directorof the Motion Lab he also directs our sports medicineprogram (CHAMPS – Children’s Health AthleticMedicine and Performance in Sports). In addition hehas a strong interest in medical leadership and hasserved as Chief of Staff at Rady Children’s Hospital,which included serving on the Board of Directors ofChildren’s Hospital. Further Rady Children’s Hospitalleadership activities include chairing the Credentials

Committee and leading the Motion AnalysisLaboratory Advisory Board. He recently co-chairedthe Miracle Foundation, an annual fundraiser forChildren’s Hospital held in a large downtown hotel,which raises hundreds of thousands of dollars in sup-port for our hospital. He also has been a key fund rais-er for the Cerebral Palsy Foundation and serves ontheir San Diego board.

Hank works closely with Children’s Hospital adminis-tration in developing new programs, recently initiatingthe Southern California Cerebral Palsy Center at RadyChildren’s Hospital to provide comprehensive cerebralpalsy care.

His congenial, inclusivepersonality has led tomany national leader-ship positions includinghis current role asPresident of theAmerican Academy ofCerebral Palsy andD e v e l o p m e n t a lMedicine. This positioninvolves travel through-out the world, including visiting lectureships in Israel,Australia, and other centers, which further establishesour international reputation. Dr. Chambers was alsorecently elected to the Board of Directors of POSNA.Further leadership responsibilities include serving asChairman of the Gait Analysis committee of POSNA,as well as working on the POSNA Evidence AnalysisWork Group.

His research covers many areas including cerebralpalsy, muscle anatomy and physiology, spasticity,sports medicine and the development of new methodsfor treating osteochondritis dissecans.

Hank’s family life includes his wife Jill and son Seanhere in San Diego, and Reid, a graduate (soon to bemedical) student in Chicago.

Mid-Career Life in Children’s Orthopedics

13

Dr. Peter O. Newton

Peter attended undergraduateschool at UCSD followed by med-ical school at Texas Southwesternin Dallas, residency at UCSD, anda pediatric orthopedic fellowshipat the Texas Scottish Rite Hospital in Dallas. Duringhis residency here he demonstrated a unique combina-tion of skills, including an engineering interest,advanced surgical skills, and a personality that encour-aged camaraderie. During his fellowship in Dallas weactively recruited Peter (against stiff competition) andfortunately he joined our faculty in 1994 and began hiscareer. Upon arrival he committed himself to 1) devel-oping the technical skills for complex spinal deformi-ty correction; 2) developing research skills to advancethe field of pediatric spinal deformity; and 3) develop-ing leadership skills.

Since joining our staff, Peter has rapidly risen tonational and international prominence due to his clini-cal and research skills in scoliosis, including the devel-opment of new techniques and implants that havegreatly improved our ability to correct scoliosis. Inaddition to being an expert clinician and skilled sur-geon he has proven to be an exceptional administrator.One sometimes fails to realize just how busy a mid-career academic track surgeon is. In addition to a fullpatient care schedule, Peter is director of our scoliosisservice and also directs our incredibly productiveresearch program, which includes the biomechanicslaboratory, the animal laboratory (in affiliation withUCSD) and our clinical outcomes studies.

He currently serves as Chief of Surgery at RadyChildren’s Hospital and as a Board member ofChildren’s Specialists-San Diego. He is the principalinvestigator of the Harms Study Group, coordinating

the 15 sites which areadministered through aSan Diego base. Thishas led to dozens ofimportant publications.He also serves as a men-tor for the UCSDresearch resident whospends a full year in ourChildren’s campus labo-ratories.

National commitments include serving as treasurer ofthe Pediatric Orthopedic Society of North America(POSNA), board member of the Scoliosis ResearchSociety (serving as Research Council Chair) andProgram Chair for the September, 2009, SRS meeting(San Antonio). Scoliosis activities include a strongcommitment to the DePuy spine education program,serving as the scoliosis education meeting chair, spon-soring live spine surgery education tutorials here inSan Diego, chairing the peer-to-peer scoliosis meetinggroup and organizing the spine deformity cadavercourse.

Ongoing research projects include an extensive annu-al research program that focuses on developing non-fusion research methods for scoliosis correctionincluding tethering of spinal growth centers. Peter alsoleads our participation in the BRAIST, NIH-sponsoredprospective bracing trial.

In addition to this incredible work schedule, Dr.Newton is a committed husband to his wife Cathy andfather to his children Alison, Kira and Walker.

Every organization has a sense of balance and benefitsby the variety of skills of its members. Although quitedifferent in many ways, Dr. Newton and Dr. Chamberseach bring a unique skill set and level of energy whichpromises to lead our program toward a strong academ-ic and scientific future.

Both Dr. Chambers’ and Newton’s commitment toclinical and scientific excellence confirms Freud’sview that a successful life consists of love and work. Ahappy, dedicated professional does not need to consid-er the work part very specifically because love notonly extends to family and friends but also to one’severyday life at “the hospital”. – DRW

Michelle Marks – Harms StudyGroup Research Coordinator

(in Tucson office)

14

Michael K. D. Benson, MA, MBBS, FRCSNuffield Orthopedic CenterOxford University – Oxford, England

Mr. Benson graduated from St. Mary’s Hospital inLondon and worked at the Middlesex and RoyalNational Orthopaedic Hospitals before undertaking aprestigious fellowship at the University of CaliforniaLos Angeles. He then returned to the UK and wasappointed as Consultant in Orthopaedic Surgery with aspecial interest in children’s orthopaedics at theNuffield Orthopaedic Centre in September 1977.

He has served as president of a number of keyorthopaedic associations and societies, including theBritish Society of Children’s Orthopaedic Surgery, theEuropean Pediatric Orthopaedic Society, and theBritish Orthopaedic Association. He also serves asPresident of the International Girdlestone OrthopaedicSociety.

Fellows plus a very cheerful Mr. Benson

Mr. Benson has published over 70 peer reviewed sci-entific papers and authored or co-authored severalbooks, including “Orthopaedics - The Principles andPractice of Musculoskeletal Surgery” and “Children’sOrthopaedics and Fractures”.

36th AnnualDavid H. Sutherland Visiting

Professorship

2008-2009 Fellows and Dr. Wenger

Mr. Benson and the current RCHSD – University of California - San Diegopediatric orthopedic staff

15

Research associatesVanessa Scott, Valerie Ugrinow,

Molly Moor, Eric Varley

Visiting Professor – 2009

Mr. and Mrs Benson, Kathy Wenger, andScott Mubarak

Burt Yaszay, Peter Newton, ShyamKishan (former fellow)

Photographs from Western Orthopedic Association – Rady Children’s Hospital Orthopedic Department eveningdinner – UCSD faculty club on April 23, 2009.

Visiting Professor NotesThe 36th Annual David H. Sutherland PediatricOrthopedic Visiting Professorship, held on April 23-24, 2009, was a fantastic success. Mr. Michael Bensonof Oxford University proved to be a brilliant visitingprofessor. He gave multiple excellent presentationsand his evening Western Orthopedic Association din-ner talk entitled “Orthopedic Humours” was one of thebest histories of orthopedic surgery that we have everheard.

Mr. Benson was able to comment on all of our clinicaland research papers and was extremely knowledgeablein every area of children’s orthopedics. He even hadcomments on the scoliosis papers and the laboratorytesting papers from the biomechanics lab related toscoliosis, although he does not treat the condition.

Our visiting professorship continues the long traditionof having the best known children’s orthopedists in theworld come to San Diego and for us to share philoso-phies with them. We learn a great deal and it helps ourprogram to remain balanced.

We also wish to announce that the 2010 VisitingProfessor has already been selected and it will be Dr.Joe Hyndman, a well known children’s orthopedic sur-geon from Halifax, Nova Scotia. The dates will beApril 22-23, 2010 and we look forward to many of ouralumni attending this event.

16

New Construction at Rady Children’s Hospital – San Diego

Rady Children’s Hospital is planning for the futurewith a new 279,000 square foot Patient Care building.The $350 million Pavilion will include 16 new state-of-the-art operating rooms, with the latest technologyto conduct pediatric surgeries. The facility will includeprivate patient rooms, outfitted with foldout sofa beds,Internet connections, and other amenities that willallow parents to be closer to their children. The PatientCare Pavilion, due to be completed in 2010, will beenvironmentally friendly with “green” technology andwill be one of the only Leadership in Energy andEnvironmental Design (LEED) certified hospitalbuildings in California.

The new parking garage was opened in Dec 2007 and providedmany new and larger spaces. The new Ronald McDonald housewas added on top and will open in June 2009 (view to south fromorthopedics office).

Construction well underway May 2009 (view to south from orthopedic office)

Architects projection – New Rady Children’s Hopstial – San Diego (to open mid 2010)

17

Connections – Images from the Orthopedic Program

Vaneeta Swaroop* (Chicago), D. Wenger (San Diego),

Meghan Imrie (current fellow)

D. Wenger (San Diego), Tracey Bastrom (research coordinator)

S. Mubarak (San Diego)

Humberto Guzman (current fellow),Tamir Bloom* (Newark), D. Wenger (San Diego),

Arjandas Mahadev* (Singapore)

D. Wenger (San Diego), Lynn Manheim, CPNP (San Diego),Mary Lou Scott, CPNP (San Diego),

P. Newton (San Diego)

Alumni ReunionPediatric Orthopedic Society of North America (POSNA) meeting, Boston – May 2009

D. Wenger (San Diego), Shyam Kishan* (Loma Linda)

Steve Frick* (Carolinas Medical Center)

Christine Caltoum* (Indianapolis), Tracey Bastrom (San Diego),

E. Edmonds* (San Diego), Patrick Henderson* (Tucson)

Sandy Mubarak,Mr. James Kock, CEO of Samuel Adams Co.

– presidential guest speaker at POSNA,S. Mubarak (San Diego)

John Schelecter* (Orange County)Professor John Dubousset (Paris)

Vaneeta Swaroop* (Chicago)

S. Mubarak (San Diego), D. Wenger (San Diego),

Dr. Ismat Ghanem - (Beirut, Lebanon)

Dr. Jean Dubousset and wife Anne with theMubaraks. Dr. Dubousset is perhaps the

world’s best know scoliosis surgeon – a for-mer visiting professor here in San Diego,

and a member of the French Legion of Honor

Other Images – POSNA Boston

* Former fellow

* Former fellow

18

Complex Cases at Rady Children’s Hospital – San DiegoDevelopment of New Surgical Methods

Our institution is known for analyzing, developing andapplying new methods to complex children’s orthope-dic problems. Often these are improved operationsdeveloped by our orthopedic staff and in other caseswe adopt methods developed in other centers.

The patient presented in this year’s issue is a beautiful14 month old Chinese girl who was the second adopt-ed child of one of our families (we had previouslytreated a sibling with a different orthopedic problem).The family called us prior to receiving the child andreported that the child had both a dislocated knee andlikely a dislocated hip, but was otherwise healthy.They asked whether we would be able to treat theproblems and of course we said yes.

Upon arrival we found the child to be a vivacious,well-nourished Chinese girl whose problem was avery deformed left lower extremity with a severe con-genital knee dislocation. In addition, x-rays showed adislocated left hip. Previous attempts at treatment inChina had included casting and splinting of thedeformed knee.

We proposed surgical treatment of both the dislocatedhip and knee, beginning with the knee. Due to the riskof severe scarring and quadriceps weakness that canfollow traditional V-Y plasty, we had to consider alter-native methods

One of our staff, who is a member of the InternationalPediatric Orthopedic Think Tank, recalled that Dr.Charles Johnston of Dallas, Texas (one of the fellowsthat Dr. Dennis Wenger had previously trained inDallas) had presented a new method for treating severeknee dislocation utilizing distal femoral shortening ata prior IPOTT meeting. This concept is similar to thatused for treating severe dislocations of the hip, butwith the knee includes complex posterior capsuleimbrication and possible cruciate ligament reconstruc-tion. The technique has not yet been published in ajournal but had just appeared in a textbook chapter.

Severe congenital knee dislocation

Child also had complete hip dislocation

19

After consulting with Dr. Johnson we took the child tothe operating room for this complex procedure whichincluded a long anterolateral knee incision, as well asa posteromedial incision for capsular imbrication (pos-terior). The quadriceps mechanism was spared. An A-O mandibular plate, which provides compression,allowed the femur to be shortened by 2 cm. The cap-sule was released and the knee freed, with it eventual-ly being flexed to 90 degrees.

A very atretic anterior cruciate ligament remained,therefore the cruciate ligament component of the pro-cedure was not performed. A separate posterior-medi-al incision as well as the lateral incision allowed pos-terior capsular reefing or capsulorrhaphy. The finaldifficulty included flexing the knee, since in this con-dition the patellar ligament (patellar tendon to some)was extremely short, requiring Z-lengthening and rein-forcement to allow knee flexion of 90 degrees.

The child was then treated with serial casting in bothflexion and extension and eventually placed in a hip,knee, ankle-foot orthosis with gradual freeing of thehinged knee. The hip will be treated by open reduc-tion, femoral shortening, capsulorrhaphy, and acetabu-loplasty in six months.

The patient is making excellent progress with goodearly knee motion and quadriceps strength, which ismuch better than one would achieve after V-Y plastyof the quadriceps. After the proposed hip surgery thechild will have femoral shortening at both ends of thefemur, all done before two years of life!

This patient exemplifies why children come fromthroughout the world for treatment in the orthopedicdepartment at Rady Children’s Hospital San Diego.Our application of innovative care by staff with greatexperience who can make the adjustments required toapply very complex treatment methods, helps to assureour reputation as an international referral center forchildren’s orthopedics.

(reproduced from Tolo, V.,and Skaggs, D. – MasterTechniques in Orthopedic

Surgery – Pediatrics)

20

Notes From a Former Fellow

Kevin G. Shea, M.D. – Boise, Idaho(1997-1998)

My interest in health care came from my parents, sincemy mother was an RN (her father was one of the firstphysicians in South Dakota) and my father was ananesthesiologist. His work ethic, honesty, and commit-ment to patients have been a great example for me. Iattended Notre Dame, studying biology and philoso-phy, and was a resident advisor in a dorm that wasmodified for students with cerebral palsy. This experi-ence influenced my decision to pursue pediatric ortho-pedics.

As a student at UCLA I worked in the Baltics duringthe initial breakup of the USSR, and Soviet tanks weresent to these areas to quell the unrest. I was struck bythe physician commitment to patient care that super-seded the problems of limited supplies and poor work-ing conditions. My work abroad (Europe, Central/South America) has provided a perspective whichtranscends nationality and geography.

I did my orthopedic residency at the University ofUtah. The pediatric orthopedic and sports medicineexperience directed me on my career path. Dr. BobBurks’ commitment to sports medicine research andexacting surgical technique continues to have a signif-icant impact on my practice. Working with Dr.Sherman Coleman was one of the great treasures ofmy training because of his humility and love of pathol-ogy and orthopedic history.

The challenge of my pediatric fellowship started withmy interview with Dr. Wenger – his questions andinsights into the human condition continue to fascinateme. Drs. Mubarak and Wenger were committed to cre-ating the best fellowship educational experience possi-ble, and this year was one of the most intense andrewarding in my life. Dr. Mubarak’s examples of com-passion, ethics, and excellence continue to guide me.

Dr. Wenger’s combined interest in history and his abil-ity to think outside the constraints of contemporarypractice never stops. I spent many afternoons review-ing gait studies with Dr. Sutherland, whose gentlekindness and teaching style impacted many patientsand students. Dr. Chambers’ commitment to neuro-muscular disease and his non-medical perspectiveabout this disease was impressive. Dr. Newton’sintense focus on spinal deformity has changed thefield, and his ‘bed side manner’ is exceptional. Dr.Wallace was a young mentor, providing me soundadvice about beginning my practice. The CHSD staffremain friends to this day, and I am grateful for theprofessional opportunities they have provided.

The camaraderie with my other fellows, Steve Frick(North Carolina), Neal McNearny (Florida), andEduardo Segal (Argentina) was another positive forthe year, and I remain in touch with each of them. Thefellows and students taught each other by sharing theirpearls of wisdom, gleaned from their own institutionsand fellowship mentors.

I joined Buzz Showalter in Boise in the fall of 1998,and Howard King joined us in 2001, providing us withhis extensive background in spinal deformity. We haveworked to create outreach clinics to cover rural areas,including Eastern Idaho and Montana. My practice hasevolved with a significant emphasis upon pedi-atric/adolescent sports medicine. Although my pri-mary focus is pediatrics and sports, my practiceincludes adult patients with knee injuries (ligament,cartilage reconstruction), trauma, Ilizarov, andosteomyelitis. I cover high school athletic programs,the College of Idaho, and the US Ski Team.

My life in Boise has been filled with some challenges,especially one of creating an academic environment in

21

a non-academic setting. I have worked with many tal-ented grad/undergrad students, and Drs. Pfeiffer andSabick at Boise State. These collaborations have leadto the development of the Center for Orthopaedics andBiomechanics Research. The research from this labhas evaluated jump/landing mechanics in young ath-letes, clinical tests for shoulder labral pathology, shoe-turf interactions for the NFL, anatomy and epidemiol-ogy of knee injury. My work at Boise State includessponsoring a graduate student fellowship in biome-chanics, serving on thesis committees, and engagingundergraduates and high school students in researchprojects. We are currently adapting the research lab forgait studies. In conjunction with Dr. Chambers andseveral other centers, we are working to create a multi-center research group for Osteochondritis Dissecans.

The quality of life in Boise and the intermountain westis remarkable – the outdoor options provide manyfamily adventures and diversions from work. My wifeLonnie and two children provide support, understand-ing and friendship.

My pediatric fellowship has had a great impact on mycareer, and the experience at CHSD was much more

than I had expected. The clinical experience was broadand deep. I was given a solid foundation for evaluatingcomplex and unfamiliar patient problems, and thisfoundation continues to support me. On a daily basis Iam guided by the experiences of my fellowship andthe ethical examples of my fellowship mentors. I quotethem with regularity and if imitation is the most sin-cere form of flattery, my pediatric orthopedic teachersshould be honored.

“The most important thing is to not stop question-ing... Truth is what stands the test of experience”

Albert Einstein

Wedding in Chicago

August was a happy time for 2007/08 fellow Vineeta Swaroop,who was married on August 30, 2008, to Chris Jaeger at the St.John Neumann Church in St. Charles, IL (near Chicago). We wishChris and Vineeta the best in their future careers and in their life together.

Vineeta is now a pediatric orthopedic surgeon at both theChildren’s Memorial Hospital of Chicago and the RehabilitationInstitute of Chicago. Since Vineeta grew up in the Chicago areaand had her residencey at Northwestern, she now has achieved alife-long goal of settling into a busy, happy life in Chicago.

The happy bride and groom

22

Documentation (Our Publications)

Our progress as a center directed to the future mandates both research and publications that docu-ment our work. We continue as one of the top children’shospitals in the world for publications in the orthopedicliterature.

Publications – July, 2007 through December, 2008

Adamczyk MJ, Odell T, Oka R, Mahar AT, Pring ME,Lalonde FD, Wenger DR: Biomechanical stability of bioab-sorbable screws for fixation of acetabular osteotomies. JPediatr Orthop, 27:314-8, 2007.

This study compared the biomechanical stability oftriple innominate osteotomies fixed with either bioabsorbable orstainless steel screws. Bioabsorbable screws behave similarly tosteel screws when stabilizing triple innominate osteotomies andwould have the advantage of not requiring a second surgery forscrew removal.

Aguinaldo AL, Buttermore J, Chambers H.: Effects of uppertrunk rotation on shoulder joint torque among baseball pitch-ers of various levels. J Appl Biomech, 23:42-51, 2007.

High rotational torques during baseball pitching arebelieved to be linked to most overuse injuries at the shoulder.This study investigated the effects of trunk rotation on shoulderrotational torques during pitching. Results suggest that a specificpattern in throwing can be utilized to increase the efficiency ofthe pitch, which would allow a player to improve performancewith decreased risk of overuse injury.

Baitner AC, Perry A, Lalonde FD, Bastrom TP, Pawelek J,Newton PO: The healing forearm fracture: a matched com-parison of forearm refractures. J Pediatr Orthop, 27:743-7,2007.

Although forearm fractures in children usually heal rap-idly after closed treatment, recent studies report forearm refrac-ture rates of 5%. The purpose of this study was to identify riskfactors for refracture based on radiographic variables.Conclusions: proximal and middle one third forearm fractures areat greater risk of refracture compared with distal one third fore-arm fractures. There was a trend toward incomplete healing seenmore commonly in those that refractured, emphasizing the impor-tance of longer immobilization in these fractures.

Berrin SJ, Malcarne VL, Varni JW, Burwinkle TM, ShermanSA, Artavia K, Chambers HG: Pain, fatigue, and school func-tioning in children with cerebral palsy: a path-analytic model.

J Pediatr Psychol, 32:330-7, 2007.This study tests a model of how pain and fatigue, inde-

pendently or in combination, relate to school functioning in pedi-atric cerebral palsy (CP). Conclusions: Pain and fatigue representpotentially modifiable targets for interventions designed toimprove school functioning in children with CP.

Bode KS, Newton PO: Pediatric nonaccidental trauma thora-columbar fracture-dislocation: posterior spinal fusion withpedicle screw fixation in an 8-month-old boy. Spine, 32:E388-93, 2007.

Case report of pedicle screw fixation in an infant withnonaccidental spine trauma. Pedicle screw fixation can be used ininfants with unstable traumatic spinal injuries, allowing earlierrehabilitation and return to normal activity level.

Goodwin R, Mahar AT, Oka R, Steinman S, Newton PO:Biomechanical evaluation of retrograde intramedullary stabi-lization for femoral fractures: the effect of fracture level. JPediatr Orthop, 27:873-6, 2007.

Retrograde stabilization of mid-diaphysis adolescentfemur fractures has shown excellent biomechanical stability.However, it is unclear whether adequate stability is maintainedfor distal femur fractures using the retrograde approach comparedwith the clinically recommended antegrade approach.Conclusions: For maximum stabilization of a distal femur frac-ture, c- and s-shaped nails placed in the antegrade position is sug-gested.

Goodwin RC, Mahar A, Wedemeyer M, Wenger D: Abductorlength alterations in hips with SCFE deformity. Clin OrthopRelat Res, 454:163-8, 2007.

Proximal femoral osteotomy may improve clinical out-comes in patients with residual deformity after slipped capitalfemoral epiphysis. Whether this procedure improves abductormechanics is not well established. There were fewer differencesin abductor lengths after femoral neck base osteotomies than aftersubtrochanteric osteotomies. The femoral neck base osteotomyapproximated normal abductor lengths more closely than the sub-trochanteric osteotomy.

23

Goodwin RC, Mahar AT, Oswald TS, Wenger DR: Screwhead impingement after in situ fixation in moderate andsevere slipped capital femoral epiphysis. J Pediatr Orthop,27:319-25, 2007.

In situ stabilization remains the standard of care in thetreatment of stable slipped capital femoral epiphysis (SCFE).Screw placement perpendicular to the physis has shown satisfac-tory results with minimal complications, however a prominentscrew head may produce femoral acetabular impingement andpain after in situ. Alternative in situ fixation techniques maydecrease the rate of screw head impingement in moderate andsevere SCFEs.

Jouve JL, Kohler R, Mubarak SJ, Nelson SC, Dohin B,Bollini G: Focal fibrocartilaginous dysplasia (“fibrousperiosteal inclusion”): an additional series of eleven cases andliterature review. J Pediatr Orthop, 27:75-84, 2007.

Focal fibrocartilaginous dysplasia (FFCD) is a benigncondition first described in 1985 as a cause of tibia vara. We arereporting on 11 cases. The lesions involved proximal tibia (9cases), distal femur (1 case), and distal ulna (1 case). We believethat this entity represents a bony anchor preventing natural slid-ing of the periosteum during growth (an "epiphysiodesis-like"effect). For the tibia, we believe this is the pes anserinus. We aresuggesting that this entity be called a "fibrous periostal inclu-sion." In tibial lesions, if the deformity worsens, early curettagewill be followed by rapid correction into physiological valgus(tibia) and prevent the need for osteotomy.

Kishan S, Bastrom T, Betz RR, Lenke LG, Lowe TG,Clements D, D'Andrea L, Sucato DJ, Newton PO:Thoracoscopic scoliosis surgery affects pulmonary functionless than thoracotomy at 2 years postsurgery. Spine, 32:453-8, 2007.

Prospective evaluation of pulmonary function beforeand 2 years after surgery following anterior scoliosis instrumen-tation to determine if thoracoscopic anterior scoliosis correctionwith instrumentation affected pulmonary function less than openthoracotomy approaches at 2 years follow-up. Conclusions: Thisstudy shows a clear advantage to the minimally invasive thoraco-scopic approach with regards to pulmonary function when com-pared with the open thoracotomy approaches

Lonner BS, Newton P, Betz R, Scharf C, O'Brien M,Sponseller P, Lenke L, Crawford A, Lowe T, Letko L, HarmsJ, Shufflebarger H: Operative management ofScheuermann’s kyphosis in 78 patients: radiographic out-comes, complications, and technique. Spine, 32:2644-52,2007.

A retrospective multicenter review of 78 patients withScheuermann's kyphosis treated operatively was conducted. Thepurpose of the study was to evaluate correction of sagittal align-ment, maintenance of correction, and occurrence of, and etiolog-ic factors associated with, junctional kyphosis in patients man-aged operatively for Scheuermann's kyphosis. This is one of thelargest reported series of Scheuermann's kyphosis treated opera-tively to our knowledge. A high rate of junctional kyphosis, espe-cially at the proximal end, is associated with surgery forScheuermann's kyphosis using current techniques. Loss of cor-rection is less in patients undergoing combined anteroposterior

surgery. Pelvic incidence correlates directly with lordosis but notkyphosis.

Mahar AT, Duncan D, Oka R, Lowry A, Gillingham B,Chambers H: Biomechanical comparison of four differentfixation techniques for pediatric tibial eminence avulsionfractures. J Pediatr Orthop, 28:159-62, 2008.

Several methods have been used to repair tibial emi-nence avulsion fractures. The purpose of this study was to com-pare the biomechanical stability of tibial eminence avulsion frac-tures using suture, resorbable screw, resorbable nail, and metalscrew techniques. Conclusions: Increased fracture separation forsutures and resorbable screw groups indicates a potential loss inreduction during cyclic, physiologic loads. There was not a clearbiomechanical advantage to performing any particular fixationmethod in this study. This suggests that the surgeon can use theirclinical judgment and experience to determine the fixation tech-nique.

Marks M, Petcharaporn M, Betz RR, Clements D, Lenke L,Newton PO: Outcomes of surgical treatment in male versusfemale adolescent idiopathic scoliosis patients. Spine, 32:544-9, 2007.

This research was part of a multicenter study of the sur-gical treatment of adolescent idiopathic scoliosis (AIS) to com-pare the radiographic and perioperative surgical treatment out-comes of male AIS patients with female AIS patients.Conclusion: Male AIS patients had slightly more rigid primarycurves compared to females but a similar degree of postoperativescoliosis correction.

Miyanji F, Mahar A, Oka R, Pring M, Wenger D:Biomechanical comparison of fully and partially threadedscrews for fixation of slipped capital femoral epiphysis. JPediatr Orthop, 28:49-52, 2008.

Previous data have shown that an equal number ofthreads on each side of the physis maximizes stability for slippedcapital femoral epiphysis (SCFE) fixation. The purpose of thecurrent study was to determine if a fully threaded cancellousscrew provides greater stability compared with a partially thread-ed screw in a porcine model. Conclusion: There was no biome-chanical benefit when using a fully threaded screw for stabiliza-tion of an in vitro SCFE model. Although there were no differ-ences between screw types in an in vitro model, bone healingaround the fully threaded screw may eventually provide greaterstability. The use of fully threaded screw remains a reasonableoption in the treatment of SCFE, and implant removal may beeasier with such a system.

Mohamad F, Parent S, Pawelek J, Marks M, Bastrom T, FaroF, Newton P: Perioperative complications after surgical cor-rection in neuromuscular scoliosis. J Pediatr Orthop, 27:392-7, 2007.

This study evaluates the perioperative complicationsassociated with surgical correction in neuromuscular scoliosisand to identify the risk factors associated with these complica-tions. Conclusions: Patients with neuromuscular scoliosis are athigh risk of developing perioperative complications after surgicalcorrection of their deformity (overall rate, 33.1%).

24

Newton PO, Upasani VV, Farnsworth CL, Oka R, ChambersRC, Dwek J, Kim JR, Perry A, Mahar AT: Spinal growthmodulation with an anterolateral flexible tether in an imma-ture bovine model: disc health and motion preservation.Spine, 33:724-33, 2008.

Spinal growth modulation by tethering the anterolateralaspect of the spine, as previously demonstrated in a nonscolioticcalf model, may be a viable fusionless treatment method for idio-pathic scoliosis. The purpose of the present study was to evaluatethe radiographic, histologic, and biomechanical results after sixand twelve months of spinal growth modulation in a porcinemodel with a growth rate similar to that of adolescent patients.Conclusions: In this porcine model, mechanical tethering duringgrowth altered spinal morphology in the coronal and sagittalplanes, leading to vertebral and disc wedging proportional to theduration of tethering.

Newton PO, Perry A, Bastrom TP, Lenke LG, Betz RR,Clements D, D’Andrea L: Predictors of change in postopera-tive pulmonary function in adolescent idiopathic scoliosis: aprospective study of 254 patients. Spine, 32:1875-82, 2007.

A multicenter study of prospectively collected pul-monary function testing and radiographic measures in patientssurgically treated for adolescent idiopathic scoliosis (AIS) wasdone to identify the factors that determine pulmonary functionmore than two years after surgery to determine what factors, ifany, can predict an increase or decrease in the percent predictedtwo year pulmonary function. Conclusion: Aside from preopera-tive PFT values, open anterior approaches predict the largest per-cent of variance in 2-year PFT. Additionally, a clinically signifi-cant reduction in the predicted 2-year pulmonary function is morelikely when performing a thoracoplasty.

Parent S, Wedemeyer M, Mahar AT, Anderson M, Faro F,Steinman S, Lalonde F, Newton P.. Displaced olecranon frac-tures in children: a biomechanical analysis of fixation meth-ods. J Pediatr Orthop, 28:147-51, 2008.

Wire and suture methods have been used to stabilizepediatric olecranon fractures. This study (1) compared differ-ences in simulated intraoperative compression during fracturereduction, (2) evaluated articular surface compression duringcyclic loading of the tension band, and (3) compared fracture sta-bilization after cyclic physiologic loading at low/high levels.Conclusions: Suture tension bands had lower ultimate failureloads and less compression at the fracture site. However, if lowloads are expected or if the fracture is reduced easily, the suturetension band may be an appropriate alternative to wire fixation insmall children or when using casts in bigger children.

Patel PN, Upasani VV, Bastrom TP, Marks MC, Pawelek JB,Betz RR, Lenke LG, Newton PO:Spontaneous lumbar curvecorrection in selective thoracic fusions of idiopathic scoliosis:a comparison of anterior and posterior approaches. Spine,33:1068-73, 2008.

A retrospective evaluation of adolescent idiopathic sco-liosis (AIS) patients treated with selective thoracic instrumenta-tion and fusion to evaluate the predictors and the effect of surgi-cal approach (anterior versus posterior) on spontaneous lumbarcurve correction (SLCC) after selective thoracic fusion in patientswith structural thoracic and compensatory lumbar curves.

Conclusion: Anterior and posterior instrumented fusions per-formed selectively on the appropriate curves result in equalSLCC when matched by LIV, flexibility of the lumbar curve, andpercent thoracic curve correction achieved. This suggests that theobserved phenomenon of SLCC after selective thoracic fusion inAIS is independent of surgical approach and can be reliablyachieved with either technique.

Perez A, Mahar A, Negus C, Newton P, Impelluso T: A com-putational evaluation of the effect of intramedullary nailmaterial properties on the stabilization of simulated femoralshaft fractures. Med Eng Phys, 30:755-60, 2008.

Titanium flexible intramedullary nails have become farmore prevalent for stabilization of pediatric femur fractures inrecent years. While steel may be expected to have superior frac-ture stability due to its higher elastic modulus; titanium alloy hasexperimentally demonstrated improved biomechanical stability,as measured by gap closure and nail slippage. The purpose of thisstudy was to verify these observations computationally, and thus,explain why titanium alloy may be better suited for surgical fixa-tion of fractured femurs. The titanium alloy nails distributedstress more evenly along the nail axis, resulting in lower peakmagnitudes. The increased deformation of the titanium alloy naillikely increases the contact area with the intramedullary canalwall, thus, increasing stability.

Petcharaporn M, Pawelek J, Bastrom T, Lonner B, NewtonPO: The relationship between thoracic hyperkyphosis andthe Scoliosis Research Society outcomes instrument. Spine2007 Sep 15;32(20):2226-31.

A retrospective chart review and radiographic analysiswas conducted to evaluate the association between thoracichyperkyphosis and patient quality of life measures as determinedby the Scoliosis Research Society (SRS) outcomes instrument.Conclusion: These findings indicate that higher kyphosis magni-tudes were associated with increased pain, lower self-image, anddecreased function and activity. Patients with thoracic hyper-kyphosis were significantly more symptomatic than normal sub-jects in all domains.

Raney EM, Freccero DM, Dolan LA, Lighter DE, FillmanRR, Chambers HG.Evidence-based analysis of removal oforthopaedic implants in the pediatric population. J PediatrOrthop, 28:701-4, 2008.

The English literature was systematically reviewed forscientific evidence supporting or disputing the common practiceof elective removal of implants in children. Conclusions: There isno evidence in the current literature to support or refute the prac-tice of routine implant removal in children.

Sanders JO, Harrast JJ, Kuklo TR, Polly DW, Bridwell KH,Diab M, Dormans JP, Drummond DS, Emans JB, JohnstonCE 2nd, Lenke LG, McCarthy RE, Newton PO, Richards BS,Sucato DJ; Spinal Deformity Study Group.The SpinalAppearance Questionnaire: results of reliability, validity, andresponsiveness testing in patients with idiopathic scoliosis.Spine, 32:2719-22, 2007.

The SAQ was designed to measure patients' and theirparents' perception of their spinal deformity's appearance usingstandardized drawings and questions. This study was designed to

25

test the instrument's psychometric properties. Conclusion: TheSAQ is reliable, responsive to curve improvement, and showsstrong evidence of validity. It provides more detail than the SRSin the appearance domain, and provides explanation of spinaldeformity's concerns and improvements.

Steinman S, Bastrom TP, Newton PO, Mubarak JS: Bewareof Ulnar Nerve Entrapment in Flexion-Type SupracondylarHumerus Fractures. J Childrens Orthopedics, 1:177-80, 2007.

A recent study reported a higher incidence of pre-opera-tive ulnar nerve symptoms in patients with flexion-type supra-condylar fractures than in those with the more common extensionsupracondylar fractures and a greater need for open reduction. Wehave encountered a specific pattern of flexion supracondylar frac-tures that often require open reduction with internal fixation(ORIF) due to entrapment of the ulnar nerve within the fracture.Conclusion: Flexion-type supracondylar fractures remain a rela-tively uncommon variant (2-3%) of supracondylar fractures.Recent reports have noted that open treatment of these fracturesis required more frequently than for extension fractures. In ourseries, 20% of the open cases were flexion-type fractures and inhalf of these the ulnar nerve was found to be entrapped in thefracture, preventing reduction.

Upasani VV, Caltoum C, Petcharaporn M, Bastrom T,Pawelek J, Marks M, Betz RR, Lenke LG, Newton PO: Doesobesity affect surgical outcomes in adolescent idiopathic scol-iosis? Spine, 33:295-300, 2008.

A retrospective review of surgical outcomes in adoles-cents with idiopathic scoliosis was conducted to determine if anassociation exists between body mass and surgical outcomes inadolescent idiopathic scoliosis (AIS). Conclusion: Overweightadolescents (BMI % >or=85) had a greater thoracic kyphosisbefore surgery compared with their healthy weight peers. Bodymass, however, did not affect the ability to achieve coronal orsagittal scoliotic deformity correction.

Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP,Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG,Newton PO: Adolescent idiopathic scoliosis patients reportincreased pain at five years compared with two years aftersurgical treatment. Spine, 33:1107-12, 2008.

A multicenter study of changes in Scoliosis ResearchSociety (SRS) outcome measures after surgical treatment of ado-lescent idiopathic scoliosis (AIS) was conducted to evaluatechanges in patient determined outcome measures between 2 and5 years after AIS surgery. Conclusion: There was a statisticallysignificant increase in reported pain from 2 to 5 years after surgi-cal treatment; however, the etiology of worsening pain scorescould not be elucidated.

Upasani VV, Chambers RC, Mubarak SJ. Analysis of calca-neonavicular coalitions using multi-planar three-dimensionalcomputed tomography J Childrens Orthopedics, 2:301-7,2008.

The purpose of this study was to evaluate three-dimen-sional (3D) multi-planar CT images of calcaneonavicular coali-tions and adjacent tarsal relationships. Conclusions: 3D CTreconstructions enabled the classification of the spectrum of cal-caneonavicular coalitions. The shape of the cuboid was found to

correlate with the extent of ossification. An understanding of the3D anatomy is important when diagnosing milder forms of coali-tions, and during resection in order to avoid iatrogenic injury tothe calcaneus, head of the talus, or cuboid.

Upasani VV, Newton PO. Anterior and thoracoscopic scolio-sis surgery for idiopathic scoliosis. Orthop Clin North Am,38:531-40, vi, 2007.

Anterior surgical treatments continue to evolve and pro-vide advantages over posterior procedures in specific instances.Open and thoracoscopic anterior approaches allow direct accessto the anterior stabilizing structures of the spine. Although theindications and contraindications for anterior versus posteriorsurgical intervention (for thoracic and thoracolumbar curve pat-terns) have been defined to some degree, there remains appropri-ate flexibility in the decision-making process.

Upasani VV, Tis J, Bastrom T, Pawelek J, Marks M, LonnerB, Crawford A, Newton PO: Analysis of sagittal alignment inthoracic and thoracolumbar curves in adolescent idiopathicscoliosis: how do these two curve types differ? Spine, 32:1355-9, 2007.

Relative anterior overgrowth has been suggested as thepossible pathomechanism behind thoracic scoliosis. Given theproposed importance of the sagittal alignment on the develop-ment of AIS and the known association between pelvic parame-ters and sagittal alignment, the authors postulate that pelvic inci-dence may influence the location of vertebral column collapseassociated with different AIS curve types. Conclusion: Anincreased pelvic incidence, associated with both thoracic and tho-racolumbar curves when compared with the normal adolescentpopulation, does not appear to be the potential determinant of thedevelopment of thoracic versus thoracolumbar scoliosis, but maybe a risk factor for the development of adolescent idiopathic sco-liosis.

Van Valin SE, Wenger DR. Value of the false-profile view toidentify screw-tip position during treatment of slipped capitalfemoral epiphysis. A case report. J Bone Joint Surg Am,89:643-8, 2007.

This paper clarifies that despite intraoperative imageintensifier confirmation and high quality postoperative radi-ographs, it is still possible that the tip of a pin can end up pene-trating the joint in slipped capital femoral epiphysis. A false pro-file view taken in an office may clarify the diagnosis even beforea CT scan has been ordered.

Wedemeyer M, Parent S, Mahar A, Odell T, Swimmer T,Newton P:Titanium versus stainless steel for anterior spinalfusions: an analysis of rod stress as a predictor of rod break-age during physiologic loading in a bovine model. Spine,32:42-8, 2007.

The in vitro biomechanical evaluation of rod stress dur-ing physiologic loading of anterior scoliosis instrumentation wasdesigned to determine effects of material properties and roddiameter on rod stresses in anterior scoliosis instrumentation.Conclusions: The percentage of yield stress was lowest for the4.75-mm Ti rod for all tests due to titanium's greater yield stress.This suggests the 4.75-mm rod has a lower fatigue failure riskthan either steel construct.

26

Wenger D, Miyanji F, Mahar A, Oka R: The mechanicalproperties of the ligamentum teres: a pilot study to assess itspotential for improving stability in children’s hip surgery. JPediatr Orthop, 27:408-10, 2007.

The anatomic and histological characteristics of the lig-amentum teres and its vascular contributions to the femoral headhave been well described. The function of the ligamentum teresremains poorly understood. Although excision is the current stan-dard in treating complete developmental hip dysplasia, we devel-oped an interest in maintaining, shortening, and reattaching theligament to assure early postoperative stability in developmentalhip dysplasia. The strength of the ligamentum teres may confirmits potential for providing early stability in childhood hip recon-structions. In the setting of dysplasia, the preservation and thetransfer of the ligamentum teres to augment stability should beconsidered as an adjunct to open reduction.

Wenger DR. Spine surgery at a crossroads: does economicgrowth threaten our professionalism? Spine, 32:2158-65,2007.

This invited presidential guest lecture was given at theScoliosis Research Society meeting in Monterey and was subse-quently published in Spine. The paper characterizes the incredi-ble growth in the medical and surgical research arena since theearly 1980s and also some of the moral hazards that spine surgeryis facing now that the nation has so many well paid spine sur-geons who use progressively more expensive and more compleximplants. Suggestions were made regarding professional organi-zations such as the SRS and how it might interface between theconsumer, the implant industry, and those who pay the bills.

Wenger DR, Mubarak SJ, Henderson PC, et al. Ligamentumteres maintenance and transfer as a stabilizer in open reduc-tion for pediatric hip dislocation: surgical technique andearly clinical results J Childrens Orthopedics, 2:177-85, 2008.

In the early surgical descriptions of both the medial(Ludloff) approach and the anterior (Salter) approach to the hip,it was generally accepted that the ligamentum teres was anobstruction to reduction and was excised (similar to the discard-ing of menisci for knee surgery in our orthopedic history). Wedeveloped surgical methods for maintaining the ligamentum tereswhen performing open reduction for hip dislocation in youngchildren. Conclusions: In this series of 23 hips, in which ligamen-tum teres transfer/tenodesis was utilized, we found no residualsubluxation or dislocation in either the medial Ludloff or the ante-rior open reduction groups. Based on these early positive results,we recommend the method for children treated with the Ludloffopen reduction procedure. Although we have less experience withit, the technique presented for ligamentum maintenance andtransfer in anterior open reduction may provide similar added sta-bility.

Willy C, Schneider P, Engelhardt M, Hargens AR, MubarakSJ: Richard von Volkmann: surgeon and Renaissance man.Clin Orthop Relat Res, 466:500-6, 2008.

Richard von Volkmann (1830-1889), one of the mostimportant surgeons of the 19(th) century, is regarded as one of thefathers of orthopaedic surgery. He was head of the Department ofSurgery at the University of Halle, Germany (1867-1889). His

powers of observation and creativity led him to findings andachievements that to this day bear his name: Volkmann's contrac-ture and the Hueter-Volkmann law.

Zhang AL, Exner GU, Wenger DR. Progressive genu valgumresulting from idiopathic lateral distal femoral physealgrowth suppression in adolescents. J Pediatr Orthop, 28:752-6, 2008.

Progressive genu varum with disturbance of medial tib-ial physeal growth (classic Blount disease) is a well-studied phe-nomenon, and in rare cases, genu varum can occur because ofmedial distal femoral physeal growth disturbance (so-calledfemoral Blount disease). To our knowledge, progressive genuvalgum caused by disturbance of lateral distal femoral physealgrowth has not been described. This article presents the history,clinical findings, imaging studies, results of surgical treatment,and speculation regarding the etiology of this disorder in 2 girlswho presented with relatively rapid progression of knock-kneeddeformity. Magnetic resonance imaging studies demonstratedunusual circular peglike disturbances of the lateral distal femoralphyses. Conclusions: Obesity and repetitive microtrauma, super-imposed on genetic factors (physis that is sensitive to compres-sive forces), may contribute to the etiology of this rare disorder.

The surest way to currupt a young man is to teach him toesteem more highly those who think alike than those who

think differently. – NIETZSCHE

27

Spreading the Word – Global Outreach

Dr. Chambers (left) and pediatric orthopedic faculty –Jerusalem – Fall 2008

(Sports and Disability Conference)

The Children’s Hospital – UCSD orthopedic faculty continue to be involved in education and researchthroughout the world.

Dennis and Kathy Wenger, and Steve andDenny Richards (POSNA President) at

EPOS presidential dinner.Lisbon, Portugal – April 2009

Left to right. George Thompson (Cleveland), ScottMubarak, Barbara Wall, Sandy Mubarak, Eric Wall

(Cincinnati - former UCSD resident), Janice Thompson.Lisbon, Portugal – EPOS

D. Wenger (San Diego),Prof. Fritz Hefti (Basel) EPOS – Lisbon – 2008

Dr. Wenger (center left), orthopedic residents, and Dr. Patricia Fucs (right) – Director of Peds. Ortho. – Santa Casa Hospital – San Paolo, Brazil – May 2008

Dr. Wenger giving “follow-up care” to his DDH surgical patient (treated at RCHSD) Damascus, Syria (April, 2009)

28

Peter Newton and Dr. and Mrs. JunTakahashi. Japanese Orthopedic

Association meeting – May 2009

Dr. Wenger and local faculty – Children’s Hospital – Florianopolis, Brazil – May 2008

Spreading the Word – Continued

Jill and Hank Chambers, Sydney, Australiafor Cerebral Palsy Meeting

S. Mubarak (San Diego), Nick Portinaro (host – Milan),

Lou Diaz (Chicago) (C.P. course – Milan, Italy – Sept. 2008)

S. Mubarak (San Diego) andCristina Alvis (former international fellow).

Cristina showed the Mubaraks around the island ofMadeira, Portugal where she is in practice

(after EPOS meeting).