H2018- Section on Orthopaedics Program: Day 2

Topic: Orthopaedics

Sponsors: Section on Orthopaedics (SOOr)

Sunday, October 23
7:00AM - 12:15PM
Moscone West, 2010

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This program will provide education in musculoskeletal medicine for Section on Orthopaedics members and general pediatricians. Students, residents, and fellows are especially encouraged to present results of their projects, with awards earned for the best presentations. The Sunday morning “10 Top Papers” provide an update on recent important sports-related literature. The section also is celebrating its 40th anniversary.

7:00AM Welcome
7:05PM Global Outreach Mentored Scholarship Program 2016
7:30AM Scientific Session IV
9:30AM Break
9:45AM Scientific Session V
11:00AM Top 10 Papers
Demorest, MD, FAAP; J. Todd Lawrence, MD, PhD, FAAP
11:55AM Presentation of Young Investigator Awards
Supported by Pediatric Orthopaedic Society of North America
12:00PM Introduction of 40th Anniversary Travel Grant Recipients
Supported by OrthoPediatrics
12:15PM Adjourn

Abstracts

8:47AM - 8:54AM
10:48AM - 10:55AM

Rebecca Demorest, MD, FAAP

Pediatric and Young Adult Sports Medicine Specialist
Webster Orthopedics
Dublin, California

J. Todd Lawrence, MD, PhD, FAAP

Pediatric Orthopaedic Surgeon
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

Presentation(s):

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Can Telemedicine Replace the First Post Op Visit for Knee Arthroscopy in Adolescents?

Sunday, October 23
7:30AM - 7:37AM
Moscone West, 2010

INTRODUCTION: A gap in the literature exists regarding comparative efficacy of a telemedicine visit with the in-office visit. Little data exists in the field of sports medicine in terms of the ability of a telemedicine visit to provide the clinician and patient with adequate information to replace office visits safely and accurately for adolescent arthroscopy patients. The purpose of this study was to evaluate the efficacy and feasibility of a telemedicine visit compared to routine post-operative visits for adolescents that had undergone arthroscopic procedures of the knee and compare physical exam findings between the two methods.

OBJECTIVES: The primary objective of this study was to demonstrate efficacy of the telemedicine visit to the office visit as measured by the ability to demonstrate range of motion, and to determine knee effusion and incision color. The secondary objectives were to determine time and mileage saved for patients and families with the telemedicine visit.

METHODS: The telemedicine visit, utilizing LYNC2013, a two-way audio/high resolution video connection, was used to conduct the telemedicine visit. Telemedicine visits were completed with the advanced practice provider and the patient and family. A standard office exam was used for the traditional office visit. The investigator visualized the incision; reviewed the surgical procedure and instructions for post-operative care and conducted the physical exam. The telemedicine visit duplicated the in-office visit and took place remotely, within twenty-four hours of the in-office visit. Patient education was provided during both visits.

Results: Thirty-four patients were included in this study. There was 100% provider agreement with incision color and effusion size when the telemedicine and in-office visit was compared. There was a statistically significant difference between physical and telemedicine exam with knee flexion range of motion (p =.005), but this difference was only 3 degrees and not clinically significant. Extension range of motion exam was similar between groups (p=.066) and not statistically significant Miles traveled ranged from 10-137 for a post-operative visit with a mean of 35 miles one way to the visit. Seventy-five percent of post-operative visits occurred on day 7.No complications were identified during either visit that required an urgent visit.

CONCLUSION: This study demonstrated excellent agreement between measurements of motion and incision evaluation between Telemedicine and outpatient visits. Patient education was provided during both visits and queries to identify potential complications were explored. This study also demonstrated that telemedicine has the potential to provide convenience and access for patients and families.

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Risk Factors for Late Diagnosis of Developmental Dysplasia of the Hip

Sunday, October 23
7:37AM - 7:44AM
Moscone West, 2010

Purpose: Limited information exists regarding the definition of late “developmental dysplasia of the hip” (DDH). The purpose of this study is to identify risk factors for late diagnosis of DDH, and to illuminate differences in treatment and outcomes.
Methods: Retrospective review of patients presenting with DDH between 1/1/2003 and 12/31/2012 and minimum 2 years follow-up was performed. Patients were categorized according to diagnosis of DDH before or after 6 months of age (ASM), and diagnosis after ambulation (AA). Data collected included: demographics, physical exam, surgical history, and imaging.
Results: One-hundred patients met inclusion criteria. Mean age at presentation was 5.2 weeks with mean follow-up 98.0 months.
Twenty-nine patients were diagnosed ASM (mean age 13.87±6.11 months). Risk factors for ASM at presentation included: normal newborn exam (88.9% (24/27) vs 41.8% (28/67) (p=0.001)) and unilateral presentation (75.9% (22/29) vs 30.2% (19/63) (p=0.001)). On exam, ASM patients demonstrated increased rates of asymmetric abduction (66.9% (19/28) vs 24.6% (16/65) (p=0.001)), asymmetric skin folds (24.1% (7/29) vs 4.6% (3/65) (p=0.005)), and negative Barlow (96.4% (27/28) vs 76.2% (48/63) (p=0.019)). During treatment, ASM patients demonstrated increased failure rate of non-operative management (88.5% (23/26) vs 39.7% (25/63) (p=0.001)) and increased surgical procedures (1.22±0.58 vs 0.51±0.89 (p=0.001)). Significant sequelae from ASM included limited flexion (17.2% (5/29) vs 4.2% (3/71) (p=0.029)), limited internal rotation (17.2% (5/29) vs 2.8% (2/71) (p=0.01)), and limited external rotation (13.8% (4/29) vs 2.8% (2/71) (p=0.036)).
There were 10 AA patients (mean age 20.79±3.89 months). At presentation, AA patients had increased frequency of normal newborn hip exam (90% (9/10) vs 51.2% (43/84) (p=0.02)). On exam, AA patients demonstrated higher rates of asymmetric abduction (77.8% (7/9) vs 38.1% (32/84) (p=0.022)), and positive Galeazzi sign (70% (7/10) vs 35.4% (29/82) (p=0.034)). AA patients were more likely to fail non-operative management (89.9% (8/9) vs 50% (40/80) (p=0.026)) and were associated with increased total complications (50% (4/8) vs 14.9% (11/74) (p=0.015)), limited range of motion (55.6% (5/9) vs 21.2% (17/80) (p=0.024)), osteonecrosis (20% (2/10) vs 4.4% (4/90) (p=0.049)), and persistent acetabular dysplasia (30% (3/10) vs 5.56% (5/90) (p=0.007)).
Conclusion: Benign newborn hip exam is a risk factor for delayed diagnosis of DDH. Patients presenting after 6 months were more likely to fail non-operative management. Risks of total complications, osteonecrosis and persistent dysplasia of the hip were increased if patients presented after walking age.

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Subtle Slipped Capital Femoral Epiphysis Is Not Associated with Cam Morphology

Sunday, October 23
7:44AM - 7:51AM
Moscone West, 2010

Background: The etiology of idiopathic cam morphology remains unclear. One prevalent theory suggests that subtle slipped capital femoral epiphysis (SCFE) leads to proximal femoral changes resulting in cam morphology. The purpose of this study was to evaluate the association between subtle SCFE and cam morphology in a large osteological collection.

Methods: We examined 962 cadaveric hips to measure two markers of cam morphology (alpha angle and anterior femoral head-neck offset) and a validated, objective marker of subtle SCFE deformity (calcar ridge line offset). When the femur is viewed medially, the calcar ridge line extends from the lesser trochanter proximally along the postero-inferior femoral neck and points towards the fovea. In SCFE-like deformity, the fovea deviates posteriorly from this projected line (Figure 1). Multiple regression analyses were performed to determine the influence of calcar ridge line offset and conventional parameters (age, femoral/acetabular version) on alpha angle and anterior head-neck offset (AHNO).

Results: There was no association between the calcar ridge line offset and alpha angle (r= -0.02) or AHNO (r=0.08). Multiple regression analysis revealed that more SCFE-like deformity (greater calcar ridge line offset) was not associated with increased alpha angle or decreased anterior head-neck offset. Furthermore, specimens whose calcar ridge line deviated one SD above the mean had a smaller alpha angle (46.6±9.1 vs 48.3±10.6, p=0.046) and greater AHNO (0.83±0.19 vs 0.77±0.16, p < 0.001), both reflecting less cam-like morphology.

Conclusion: Subtle SCFE-like deformity, as objectively measured from the calcar ridge line, was not predictive of more cam-like morphology. Further study is needed to identify other potential etiologies of idiopathic cam morphology.

Figure 1
The calcar ridge line is a previously published, objective marker of subtle slipped capital femoral epiphysis deformity. When the femur is viewed medially, the calcar ridge line (dashed black line) extends from the lesser trochanter proximally along the postero-inferior femoral neck and points towards the fovea (dashed circle, top). In SCFE-like deformity, the fovea deviates posteriorly from this projected line (bottom).

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A Cadaveric Investigation into the Demographic and Bony Alignment Properties Associated with Osteoarthritis of the Patellofemoral Joint

Sunday, October 23
7:51AM - 7:58AM
Moscone West, 2010

Purpose: Patellofemoral joint osteoarthritis is common, although circumstances dictating its evolution and pathogenesis remains unclear. Advances in surgical technique have improved the ability to modify long-bone alignment in the coronal, sagittal, and axial planes. However, to our knowledge, there is no significant long-term data available in regards to the relationship between anatomic the alignment parameters most amenable to surgical modification and patellofemoral joint osteoarthritis.

Methods: Five-hundred and seventy-one cadaveric skeletons were obtained from the Hamann-Todd osteological collection. Information regarding age at time of death, gender, race, and height were recorded. Mechanical lateral distal femoral angle, medial proximal tibial angle, tibial slope, femoral version, tibial torsion, the position of the tibial tubercle relative to the width of the tibial plateau, trochlear depth, and patellar size were measured using validated techniques. A previously published grading system for patellofemoral joint arthritis was used to quantify macroscopic signs of degenerative joint disease.

Results: Increasing age (standardized beta 0.532, p< 0.001), female gender (standardized beta 0.201, p=0.002), and decreasing mechanical lateral distal femoral angle (standardized beta -0.128, p= 0.025) were independent correlates of increased patellofemoral joint osteoarthritis. A relatively more laterally positioned tibial tubercle trended towards predicting patellofemoral joint osteoarthritis (standardized beta 0.080, p= 0.089).

Conclusion: These findings confirm that patellofemoral joint osteoarthritis is strongly associated with increasing age and female gender. Valgus alignment of the distal femur, a relatively more lateral location of the tibial tubercle, and a shallower trochlear grove appear to have modest effects on the development of patellofemoral joint osteoarthritis.

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Fixation of Chondral-only Shear Fractures of the Knee in Pediatric and Adolescent Athletes

Sunday, October 23
7:58AM - 8:05AM
Moscone West, 2010

Purpose:
Attempted fixation of acute osteochondral shear injuries of the knee, though rare, is generally pursued in young, active patients, provided the adequately-sized fragment contains substantial bony tissue. Traditional biological principles suggest cartilage alone cannot be reaffixed to bone. However, due to several case reports of successful fixation of chondral-only fragments, this concept remains controversial and incompletely explored. The purpose of the current study was therefore to evaluate the presenting features, techniques, rates of healing, clinical, and radiological results in a cohort of youth athletes who underwent fixation of chondral-only fragments.

Methods:
An IRB-approved departmental database review at a regional tertiary care children’s hospital identified patients ≤18 years old who underwent fixation of a ‘chondral-only’ fragment in the knee, which was defined by the inability to visualize the fragment on injury radiographs or discern bone on the fragment intra-operatively. Mechanism of injury, fragment features, fixation technique, timing of sports clearance, healing on postoperative MRI, and any complications/re-operations were assessed. Descriptive statistics were reported as medians and interquartile ranges (IQR) in order to minimize the skew effect of outliers, which is of concern in reports of rare conditions.

Results:
Ten patients met inclusion and exclusion criteria. Median age at the time of surgery was 12.5 years old (IQR:11.7-13.3), and median follow-up was 12 months (IQR:6-22 months). All patients sustained an acute knee injury prior to surgery, including self-reported patellofemoral instability events (N=6), fall onto flexed knee (N=2), and hyperextension (N=2). Injury sites were trochlea (N=4), patella (N=3), and lateral femoral condyle (N=3). Median fragment size was 484mm2 (IQR:400-600mm2). Arthrotomy, with or without preceding arthroscopy, was pursued in all cases, which were performed at a median of 1.3 weeks (IQR:1.0-2.0 weeks) post-injury. Fixation implants included bioabsorbable tacks alone (N=7), bioabsorbable screw and suture (N=1), bioabsorbable screw and tacks (N=1), absorbable suture alone (N=1). One patient (10%) sustained a reinjury 8 weeks postoperatively, requiring secondary surgery for fragment excision, and one (10%) underwent patellar stabilization surgery 3.4 years post-operatively, at which time the fragment was found to be stable. Postoperative MRI to assess the fragment was performed in 6/10 subjects at a median of 1.0 years postoperatively, with 3(50%) showing restoration of cartilage contour and subchondral edema resolution. 1/6 showed thinning of cartilage with an intact contour, 1/6 had cartilage thickening, and 1/6 had subchondral edema, fissuring, and cystic changes. Median time to return to sports was 25.9 weeks (IQR:24.1-24.8 weeks).

Conclusion:
There is minimal literature to guide treatment of chondral-only shear fractures of the knee. The results of this study suggest that acute fixation of chondral-only fragment using absorbable implants should be considered in pediatric or adolescent athletes and may result in successful healing in the majority of patients.

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Early Mpfl Repair After Patellar Dislocation in Adolescents Does Not Treat Anatomic Risk Factors for Repeat Instability

Sunday, October 23
8:05AM - 8:12AM
Moscone West, 2010

Background: Non-operative treatment has been the mainstay for pediatric patients with patellofemoral instability. Some advocate that surgical treatment could decrease the incidence of repeat dislocation.
Questions/purposes: The purpose of this study was to determine the incidence of repeat dislocation or instability events amongst patients treated with or without surgery after a first time patellar dislocation. Our hypothesis was that medial patellofemoral ligament (MPFL) repair would decrease the rates of dislocation and instability events as compared to non-operative management or arthroscopic excision of loose body alone.
Methods: A single site database search using ICD-9 codes was performed, and 107 patients (aged 10-18 years) with first time, acute ( < 2 week) patella dislocations that met criteria were identified. They were grouped according to treatment: non-operative treatment (n=71) and operative treatment (n=36). The operative group was subdivided: arthroscopy with loose body removal (n=15) and arthroscopy with loose body removal plus MFPL repair (n=21). Clinical outcome data on repeat instability events (subluxation and dislocation) and measurements of important anatomic relationships were compiled in a retrospective fashion.
Results: The rate of re-dislocation was 40% for the non-operative treatment group and 14% for the operative treatment group (p < 0.01). The rate of at least one instability event between groups was 49% in the non-operative treatment group and 22% in the operative treatment group (p < 0.01). There were no differences between the operative subgroups with re-dislocations in 13% of the arthroscopy with loose body removal versus 14% of the arthroscopy with loose body removal group plus MPFL repair group (p=0.94) and an incidence of any instability event in 27% of the arthroscopy with loose body removal versus 19% of the arthroscopy with loose body removal group plus MPFL repair group (p=0.59). Anatomic measurements of all first-time dislocation patients with magnetic resonance imaging (MRI) available (n=72) showed significant differences in trochlear inclination (p < 0.01), trochlear asymmetry (p < 0.01), trochlear depth (p < 0.01), Insall-Salvati Ratio (p < 0.01), and Caton-Deschamps Index (p < 0.01) compared to normal values. In addition, patients with repeat instability were significantly different in trochlear inclination (p=0.02), trochlear asymmetry (p < 0.001), and trochlear depth (p < 0.01) compared to those without repeat instability.
Conclusions: Adding MPFL repair to arthroscopy with loose body removal for treatment of acute patella dislocation does not reduce the incidence of repeat dislocation or repeat instability events. MRI measurements of trochlear dysplasia may be more predictive of future instability. Future prospective trials in which treatment was based on anatomic relationships as measured on MRI would help confirm our initial findings.

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The Effect of Tunnel Drilling Angle on Physeal Disruption During Acl Reconstruction in Skeletally Immature Patients: Transtibial vs. Independent Drilling

Sunday, October 23
8:12AM - 8:19AM
Moscone West, 2010

Purpose: Most studies examining the safety and efficacy of transphyseal ACL reconstruction for skeletally immature patients have utilized transtibial drilling. Independent femoral tunnel drilling may impart a different pattern of distal femoral physeal involvement. The purpose of this study was to radiographically assess differences in distal femoral physeal disruption between transtibial and independent femoral tunnel drilling, paying particular attention to tunnel angle in relation to the physis. We hypothesized that more oblique tunnels associated with independent drilling involve a significantly larger area of physeal disruption compared to vertically oriented tunnels.

Methods: Skeletally immature patients between 10 and 15 years of age who underwent transphyseal ACL reconstruction utilizing an independent femoral tunnel drilling technique between January 1, 2008 and March 31, 2011 were analyzed. These patients were matched with a transtibial technique cohort based on age and sex. Pre-operative baseline MRI was utilized to determine the estimated total cross-sectional area of the femoral physis for each patient by tracing a custom region of interest (ROI) along the physeal border of axial images. Post-operative AP and lateral x-rays were used to measure the width/length of the portion of the physis that was removed, angle of the femoral tunnel, and location of the center of the femoral tunnel.

Results: Ten patients were analyzed in each group. There were significant differences between independent drilling and transtibial drilling cohorts in femoral tunnel angles (32.1º vs. 72.8º, P < 0.001), the resultant estimated area of physeal disruption (1.64 cm2 vs. 0.74 cm2, P < 0.001), and medial/lateral location of the femoral tunnel (24.2 mm vs. 36.1 mm from lateral cortex, P=0.001), respectively (Fig 1). There was a significant inverse correlation between femoral tunnel angle and estimated area of distal femoral physeal disruption (r=-0.8255, P=0.003, Fig 2).

Conclusions: Femoral tunnels created with an independent tunnel drilling technique in this cohort were more horizontal and disrupted a larger area of the distal femoral physis, creating more eccentric tunnels compared to a vertical transtibial technique. Surgeons should be aware that femoral tunnel obliquity should therefore be minimized as much as possible (regardless of tunnel drilling method) in order to limit physeal disruption during transphyseal ACL reconstruction.

Figure 1. Table of Anatomic Measurements
Table depicting the anatomic measurements for the series. The mean femoral tunnel angle, width of the femoral tunnel, and area/percentage of physis removed were significantly different between the independent and transtibial groups (p<0.001). In addition, patients undergoing independent drilling had tunnels that were significantly closer to the lateral cortex as well as the perichondrial ring compared to patients in the transtibial series (p<0.001).
Figure 2. Scatterplot of Femoral Tunnel Drill Angle and Physeal Damage
A scatterplot highlighting the relationship between the femoral tunnel drill angle and the percentage of the distal femoral physis that was damaged. As the femoral tunnel drill angle decreased relative to the femoral condyles, the proportion of affected physis increased. This relationship was shown to be significant (r=-0.8255, P=0.003).

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Pediatric Anterior Glenohumeral Dislocation Risk Factors Measured on Magnetic Resonance Imaging (mri)

Sunday, October 23
8:26AM - 8:33AM
Moscone West, 2010

Purpose: In the adult population, anterior glenohumeral instability has been associated with a tall and narrow glenoid morphology, assessed as glenoid index (GI). This morphological association has not been assessed in children and adolescents. This study was designed to examine the association of GI with anterior glenohumeral dislocation in patients 19 years old and younger using a case-control study design.

Methods: An institutional radiology database was queried over a 10-year period to identify patients 19 years old and younger who underwent glenohumeral MRI arthrography and diagnosed with anterior shoulder dislocation (cases) and those without dislocation and normal shoulder arthrogram studies (controls). Those with bony Bankart lesions were excluded. Glenoid index (glenoid height-to-width ratio, Figure 1) was measured by an attending pediatric musculoskeletal radiologist and a fellowship-trained attending orthopedic surgeon. Comparative analysis was performed using Student’s t-Test, followed by receiver operating characteristic (ROC) analysis to determine discriminative ability.

Results: Thirty-three males and 22 females (mean age: 15.4±2.1 years old) meeting inclusion and exclusion criteria were identified. Mean glenoid index in the dislocator group was significantly greater than the control group (1.55±0.14 vs. 1.38±0.08, P < 0.001). ROC analysis revealed adequate discrimination of glenoid index in predicting glenohumeral dislocation (area under the curve [AUC] = 0.88). A glenoid index ≥1.45 was 83% sensitive and 79% specific for predicting dislocation in the study cohort (Figure 2).

Conclusion: Patients with anterior glenohumeral dislocation were noted to have increased GI (taller and narrower glenoid morphology) than controls. Glenoid index may help identify patients at risk for primary or recurrent anterior glenohumeral instability events, and can help guide treatment and anticipatory guidance.

Measurement of Glenoid Index on MR Arthrogram
Glenoid Index=Height/Width=A/B; Height: superior glenoid tubercle to the inferior glenoid, Width: widest part of the glenoid, perpendicular to the height axis; Sequence: T1-weighted fat suppressed MR arthrogram image in the sagittal oblique plane, en face to the glenoid surface.
ROC Analysis of GI as a Predictor of Shoulder Dislocation
ROC analysis of GI as a predictor of shoulder dislocation. Area Under Curve = 0.88 (threshold of acceptability is >0.80);
Glenoid index ≥1.45 (arrow) was 83% sensitive and 79% specific for predicting dislocation in this cohort.

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Periacetabular Osteotomy to Uncover the Hip: Uncommon Variations on a Common Procedure

Sunday, October 23
8:33AM - 8:40AM
Moscone West, 2010

Purpose: Periacetabular osteotomy (PAO) is a versatile acetabular reorienting procedure that is most commonly used to provide greater femoral head coverage in adolescent hip dysplasia. However, PAO can also be used to reorient the acetabulum in the opposite direction to treat femoroacetabular impingement (FAI) due to acetabular over-coverage. We describe the indications, surgical technique, and early results of reverse PAO to reduce femoral head coverage in symptomatic hips with FAI due to acetabular over-coverage.

Methods: IRB approval was obtained to retrospectively review cases of symptomatic acetabular over-coverage treated with reverse PAO and that had a minimum of two years follow-up. All hips had atypical intraoperative positioning of the acetabular fragment to uncover the lateral and anterior aspects of the femoral head, with or without anteverting the acetabulum. Prospectively collected pre- and post-operative demographics, WOMAC scores, Modified Harris Hip Score (MHHS), EuroQol Five Dimensions (EQ-5D), and radiographic measurements consisting of the lateral center edge angle (LCEA), Tönnis angle (TA), and anterior center edge angle (ACEA) were compared using student’s t-test.

Results: Between 2004 and 2015, 31 hips (18 left, 13 right) in 26 patients (18 female, 8 male) met the inclusion criteria. Average age at the time of surgery was 19.4 years. Average length of follow-up was 28 months. After reverse PAO, femoral head coverage significantly decreased (LCEA 41.7° to 35.3°, p < .001; TA -7.4° to -3.7°, p < .01; ACEA 44.0° to 35.3°, p < .0001). Patients experienced improved post-operative pain , with decreases in WOMAC pain score (from 8.8 to 3.8, p < .001) and WOMAC stiffness score (from 3.5 to 1.6, p < .0001). Patients also experienced improvements in function and quality of life with improvements in WOMAC function score (from 24.8 to 8.8, p < .0001), MHHS (from 60.8 to 83.6, p < .0001), and EQ-5D VAS (from 75.3 to 87.5, p < .01).

Conclusion: Reverse PAO is a technically challenging procedure that provides clinical and radiographic improvement in patients with symptomatic FAI due to acetabular over-coverage. Reverse PAO is an especially useful and appropriate alternative to arthroscopic acetabular rim-trim in complex FAI pathomorphologies.

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Capital Femoral Growth Plate Extension Predicts Cam Morphology in a Longitudinal Radiographic Study

Sunday, October 23
8:40AM - 8:47AM
Moscone West, 2010

Background: Recent evidence has suggested that cam morphology may be related to alterations in the capital femoral growth plate during adolescence. The purpose of this study was to evaluate the relationship between capital femoral growth plate extension and cam morphology in a longitudinal radiographic study.

Methods: We utilized a historical, longitudinal radiographic collection to identify 96 healthy adolescents (54 males and 42 females) with at least five consecutive, annual films of the left hip including closure of the capital femoral physis. We reviewed 554 anterior posterior (AP) films of the left hip to measure the AP modification of the alpha angle of Notzli and the superior epiphyseal extension ratio (EER), measured as the ratio of extension of the capital femoral epiphysis down the femoral neck relative to the diameter of the femoral head. Measurements were made at three points in femoral head maturation corresponding to the Oxford Bone Age (OBA) femoral head stages 5, 6, and 7/8.

Results: There was a mean increase in AP alpha angle (10.7±14.0 degrees) and EER (0.12±0.08) between OBA stages 5 and 8, corresponding to maturation and closure of the capital femoral physis. There was a positive correlation between final AP alpha angle and both final EER (r=0.60) and the change in EER (r=0.58). A receiver operating characteristic curve generated to predict AP alpha angle >78 degrees through EER demonstrated an area under the curve of 0.93, reflecting that increasing EER had excellent diagnostic accuracy for predicting concurrent cam morphology.

Conclusion: Superior epiphyseal extension was directly and temporally associated with an increase in AP alpha angle and more cam-like morphology. This alteration in the capital femoral epiphysis occurred immediately before physeal closure (OBA 7/8). Given its association with activities that increase shear forces across the physis, we propose that epiphyseal extension may be an adaptive mechanism to stabilize the physis and prevent slipped capital femoral epiphysis.

Figure 1
Anterior-posterior (AP) views of the left hip in a developing adolescent male. Development of cam morphology (as measured by AP alpha angle) occurs concomitantly with increasing capital femoral epiphyseal extension (EER) around the time of physeal closure.

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Injuries in the Competitive Pediatric Motocross Athlete

Sunday, October 23
8:47AM - 8:54AM
Moscone West, 2010

Purpose
Motocross is a high impact sport popular amongst the pediatric population with the potential for severe injury. Unlike other contact sports, little has been studied about the injuries sustained by children while participating in competitive motocross. The purpose of this study is to identify the epidemiological factors and injuries related to competitive motocross racing in the pediatric population in order to identify aspects of the sport that can be modified to improve its overall safety.

Methods
An IRB approved, retrospective study of pediatric trauma activations sustained during competitive motocross racing treated at a level I trauma center between 2004 and 2014 was performed. Patients were included if less than 18 years of age and injured while practicing or competing on a two-wheeled dirt bike at an American Motorcycle Association (AMA) sanctioned motocross track. Medical records were retrospectively reviewed including initial trauma evaluation, hospitalizations, treatments, and all subsequent clinical visits related to the injury. Data included age, sex, race, location of accident, use of safety equipment, mechanism of injury, injury type and severity, Glasgow Coma Score at hospital presentation, and Injury Severity Score (ISS).

Results
35 patients were studied. The average age was 14 years (range 8 to 17) and all patients were white males. The highest incidence of injuries occurred during May and August. 85.7% of injuries occurred on the weekend. One patient died. 30 patients were injured during competition; 5 were injured during practice. 25 patients (71.4%) suffered an orthopaedic injury with a total of 32 fractures and 2 dislocations. Two fractures were open (6.3%). Lower extremity fractures were twice as common as upper extremity fractures. Surgery was more common for upper extremity fractures--83% vs 30%. The most common fractures were femoral shaft (18.8%), fibula (12.5%), clavicle (12.5%), tibial shaft (9.4%) and forearm (9.4%). All 35 patients were wearing the AMA required equipment, including a helmet, shatter proof goggles, protective pants, long sleeve jersey, and protective boots at the time of injury. 17 (48.6%) patients sustained a concussion with the highest incidence at the 15 year old age group. The Injury Severity Score (ISS) exhibited a bimodal distribution. ISS of 25 in the 10 to 11 year age group and ISS of 15 in the 15 to 16 year age group.

Conclusions
Competitive pediatric motocross athletes suffer serious, potentially life-threatening injuries despite the required use of protective safety equipment in AMA sanctioned events. Injuries were more common during competition. All patients were white males with an average age of 14 years. May and August had the highest incidence of injuries and most injuries occurred on the weekend. Femoral shaft, fibula and clavicle were found to be the most commonly fractured bones. Despite the required use of helmets, nearly half of the patients suffered concussions.

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Increased Time to Surgery in Slipped Capital Femoral Epiphysis Results in Increased Southwick Angle, Complications and Need for Future Significant Surgery

Sunday, October 23
8:54AM - 9:01AM
Moscone West, 2010

Purpose: Present recommendations for the management of slipped capital femoral epiphysis (SCFE) are prompt hospital admission, bed rest, and urgent surgical stabilization. The rationale for doing so is rooted in the presumed prevention of deformity progression. For many of the SCFE patients served by our hospital, there is a significant delay between diagnosis and surgical stabilization due to long distance transportation from less developed regions. Therefore, in this study, variation in time between diagnosis and surgery for SCFE as related to slip severity and complications (including need for further surgery) was assessed.

Methods: Following institutional review board approval, the medical records of 125 patients (156 hips) surgically treated for SCFE between 1995 and 2014 were reviewed. Bilateral cases were counted separately. Patients’ residential locations were stratified by geographic region. Patient demographics, time between diagnosis and surgery, radiographic findings (Southwick angle), duration of antecedent symptoms prior to diagnosis, post-operative complications, and need for further significant surgery were variables of interest. Statistical analysis included Pearson and Spearman rank correlations and chi-square tests

Results: Patients (hips) with time between SCFE diagnosis and surgery of greater than one year were excluded from analysis. The study sample was comprised of 147 hips (119 patients, 28 bilateral cases), or 91 males (62%) and 56 females (38%), with a mean age of 12 years (sd = 1.9, range of 7.3 - 1 7.8 years) at the time of surgery. The overall mean time between diagnosis and surgery was 20.9 days (sd = 46, range = 0 - 321). The average Southwick Angle (SA) at time of in-situ fixation was 31.9˚ (sd = 19.6˚, range of 1-83˚).

There were statistically significant correlations between time from diagnosis to surgery and SA (0.34, p < 0.001). SA was found to be correlated with significant future surgery (0.27, p < 0.01), weight (0.20, p < 0.05), height (0.36, p < 0.001), and age at diagnosis (0.37, p < 0.0001).

Chi-square tests indicated that a significantly greater number of patients from less-developed regions, with transportation challenges for accessing care, had moderate and severe SA (Χ2=14.93, df=4, p < 0.01), and required significant further surgery than those from our local population (Χ2=10.72, df=2, p < 0.01).

Conclusion: The unique outreach and referral environment of our hospital provided an opportunity to further examine present recommendations for treating SCFE. Our study’s findings supported the traditional anecdotal orthopedic teaching that children with a greater delay between diagnosis and treatment of SCFE will present with increased radiographic deformity and have inferior clinical outcomes. Furthermore, weight (as opposed to BMI) was noted to be of consequence with regard to slip severity and its progression.

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Oral (Podium)

Pelvic Incidence Is Influenced by Pelvic Rotation in Plain Radiographs

Sunday, October 23
9:01AM - 9:08AM
Moscone West, 2010

Purpose:
Pelvic incidence (PI) is an important spinopelvic parameter that is a major determinant in spine and hip pathology. PI is ideally measured using a lateral radiograph, and the midpoint of the two femoral heads is commonly used as an approximation when the view is slightly rotated. The accuracy of using this approximation has not been rigorously studied and is important to better understand as the understanding of PI continues to grow.

Methods:
This was a descriptive laboratory study utilizing the Haman-Todd cadaveric research collection. Fluoroscopic images of six reconstructed adult pelves and femora were taken at six positions of rotation. PI was measured at each position using the center of the near femoral head (CNear), center of the far femoral head (CFar), and midpoint between the centers of the femoral heads (CMid) as three different reference points. PI error was defined as the difference in PI using each method measured at different positions compared to true PI measured using a lateral radiograph. 95% confidence intervals were determined for PI error at each position of rotation.

Results:
PI was measured from radiographs rotated 0°, 5°, 10°, 15°, 20°, and 25° from the lateral position. PI error was 8.3° (95% CI 7.4°-9.1°) and 19.5° (95% CI 17.2°-21.9°) in radiographs using CNear as a reference point that were rotated 10° and 25° respectively. PI error was 8.5° (95% CI 7.4°-9.7°) and 21.1° (95% CI 17.3°-24.9°) in radiographs using CFar as a reference point rotated 10° and 25° respectively. PI error increased when using CNear or CFar as a reference point with increasing rotation of pelvic radiographs. However, when using the midpoint of the center of femoral heads as a reference point, PI error was 0.6° (95% CI 0.2°-1.0°) in a radiograph rotated 10° and 1.6° (95% CI 0.7°-2.4°) degrees in a radiograph rotated 25°.

Conclusion:
Pelvic rotation significantly influences the measurement of PI when using the center of either the near or far femoral head as a reference point. Using the midpoint between centers of the femoral heads on a rotated pelvic radiograph provides an accurate measurement of PI even up to 25 degrees of image rotation. Rotated lateral radiographs are appropriate to use to determine PI, and even a proper false profile radiograph (taken 25 degrees from lateral) can be used to accurately measure pelvic incidence. These findings have important implications in the future research of PI and its effect on spine and hip pathology.

Figure 1
Three separate methods for calculating PI from a rotated pelvic radiograph
Figure 2
PI error at different degrees of rotation using three different methods of measurement

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Oral (Podium)

Both Decreased and Increased Relative Acetabular Volume Are Associated with Increased Hip Arthritis in an Osteological Review of 1090 Hips

Sunday, October 23
9:08AM - 9:15AM
Moscone West, 2010

Purpose: Recently, there has been considerable interest in quantifying the associations between bony abnormalities about the hip joint and osteoarthritis. The relationships between acetabular undercoverage, acetabular overcoverage, and femoroacetabular impingement (FAI) with hip joint osteoarthritis (HOA) remain controversial.

Methods: 545 cadaveric skeletons (1090 hip joints) from the Hamann-Todd osteological collection were obtained. Femoral head volume (FHV), acetabular volume (AV), the ratio between femoral head volume and acetabular volume (FHV/AV), acetabular version, alpha angle, and anterior femoral neck offset (AFNO) were measured. A validated grading system was used to quantify HOA as minimal, moderate, or severe. Multiple linear regression was used to determine the independent correlates of FHV, AV, and FHV/AV. Multinomial logistic regression was used to determine which factors increase the risk of HOA.

Results: Females had smaller FHVs (standardized beta -0.382, p < 0.001), and AVs (standardized beta -0.351, p< 0.001), although the ratio of FHV/AV was unchanged. Every 1-degree increase in alpha angle increased the probability of having moderate HOA compared to minimal HOA by 7.1%. Every 1-millimeter decrease in AFNO increased the probability of having severe or moderate HOA, compared to minimal HOA, by 11% and 9%, respectively. The relative risk ratios of having severe HOA compared to minimal HOA were 7.2 and 3.3-times greater for acetabular undercoverage and overcoverage, respectively, relative to normal acetabular coverage.

Conclusions: Both acetabular undercoverage and overcoverage are associated with hip arthritis, supporting the growing viewpoint that overcorrection of either condition is unfavorable. Acetabular undercoverage and overcoverage were independent predictors of increased HOA. Alpha angle and AFNO had modest effects, supporting the hypothesis that bony abnormalities both in the dysplastic and FAI spectrum increase the risk for more severe HOA.

Measuring Acetabular Volume
Figure2.tif
Acetabular volume was measured according to a half-spheroid model. A distance across the acetabulum was measured inline with ASIS and ischial tuberosity (heavy dotted blue line). Another perpendicular measurement was taken across the acetabulum (lightly dotted green line). Acetabular depth was measured from the stereotactic center of the two measurements spanning across the acetabulum to the deepest point in the acetabulum (red line).

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Oral (Podium)

A Perspective on Pavlik Harness Disease: Does Prolonged Treatment of a Dislocated Hip in a Harness Adversely Affect the Alpha Angle?

Sunday, October 23
9:15AM - 9:22AM
Moscone West, 2010

Purpose: Current dogma contends that continued use of a Pavlik harness beyond 3 weeks with a dislocated hip will cause “Pavlik harness disease” or erosion of the posterior acetabulum, making subsequent hip reduction more challenging. To our knowledge, however, no previous studies have documented objective morphologic changes to the acetabulum in response to continued Pavlik treatment of a persistently dislocated hip.

Methods: We retrospectively reviewed a consecutive series of infants with DDH < 6 months old who failed Pavlik harness treatment from a single, tertiary care pediatric hospital and a multi-center, international study group. Inclusion criteria were dislocated hips confirmed by ultrasound (both initially and at Pavlik termination) and a minimum of two ultrasounds during harness treatment at least three weeks apart. As a global measure of acetabular morphology, alpha angle was compared between initial and final ultrasound, and the final means of obtaining successful hip reduction was recorded.

Results: Forty-nine hips in thirty-eight patients were identified. Median age at Pavlik initiation was 4 weeks (range, 0–18) and median time in harness was 6 weeks (range, 3–14). Surprisingly, a mean 4° improvement in alpha angle (95% CI, 2–6°; p=0.001) was observed between first and final ultrasound, with no significant change in femoral head coverage (p=0.853). We found no difference in change in alpha angle between those in harness 3–5 weeks and those with prolonged wear >5 weeks (p=0.521). There was no significant association between change in alpha angle and time in harness (p=0.545), age at Pavlik initiation (p=0.105), clinical reducibility of the hip (p=0.224), or femoral head coverage at initial (p=0.956) or final ultrasound (p=0.651). Following harness failure, 22 of 49 hips (45%) were successfully treated with rigid abduction bracing, 16 (33%) by closed reduction/spica casting and 10 (20%) by open reduction; 1 hip (2%) was found to spontaneously reduce and required no further treatment. Only 1 hip (2%) failed open reduction and required additional revision surgery. There was no significant difference in the proportion of patients treated successfully via closed means between those with a decrease in alpha angle vs. those that improved or remained stable (87% vs. 76%; p=0.702), and no differences between those in harness >5 weeks vs. those < 5 weeks (75% vs. 83%; p=0.720).

Conclusion: Based on the lengths of harness treatment in our series and coronal ultrasonographic metrics, most hips did not exhibit negative changes in the acetabular alpha angle in response to prolonged treatment of a dislocated hip in harness. Furthermore, 80% of hips failing harness treatment were successfully reduced via closed means, indicating that subsequent treatment was not compromised. Further investigation is required to definitively confirm or refute the presence of “Pavlik harness disease”.

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Oral (Podium)

Failing Bones in the Youngest Athletes: 217 Cases of Stress Fractures in Children 8-14 Years Old

Sunday, October 23
9:22AM - 9:29AM
Moscone West, 2010

Introduction: With the growing professionalization of youth sports and the increase in year-round training, problems and injuries once seen only skeletally mature athletes are now seen in children. Although there have been a few studies of stress fractures in adolescent athletes, there are no published series of stress fractures in the pre-adolescent athlete. The purpose of our study was to investigate stress fractures in children 8-14 y/o, analyzing the patterns and differences in age, gender, sport, and site of the stress fracture.
Methods: After IRB approval, we analyzed a billing record database and review of patient records between 2009 and 2015 to identify stress fractures in patients between the ages of 8 and 14. Data collection included gender, age, sport/activity, and site of fracture. We used a one sample proportion z-test to determine statistical significance.
Results: 217 stress fractures were identified in patients ages 8-14. There was a strong, statistically significant female predominance for stress fractures (female: 136/217, male: 81/217, P < .001). Interestingly, the gender trend varied by age: there was no significant difference in the younger group, ages 8-10 (female: 39/63, male: 24/63, P=.1228), but there was a statistically significant difference in the older group, ages 12-14 (female: 97/154, male: 57/154, P=.00127). The most common sport associated with stress fracture in children was competitive running, such as track and cross country (61/217=28.1%), followed by soccer, gymnastics, and dance. The most common site of injury was the tibia (84/217=38.7%), followed by metatarsal/foot (59/217=27.2%). For upper extremity stress fractures, 50% occurred in throwers (baseball/softball), and 39.3% in gymnasts from upper extremity weight bearing.
Conclusion: This is the first known series describing stress fractures in younger children. In this population of 8-14 year olds, we found a significant predominance in females, especially in the older cohort of our study population. The site of stress fracture and the sports causing the most stress fractures mirror the patterns reported in skeletally mature athletes. These results should raise awareness of stress fractures risk in the youngest athletes. The strategies currently used to prevent stress fractures in high school and college athletes may benefit our youngest athletes as well.

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When Are Static/moving Two Point Discrimination and Semmes-weinstein Monofilament Tests Reliable in Children?

Sunday, October 23
9:45AM - 9:52AM
Moscone West, 2010

Purpose
Objective sensory testing is a critical component of the physical examination, especially when lacerations occur. This is especially true in children as they may be unable to communicate if numbness is present. The purpose of this study was to determine at what age objective sensory tests could reliably be performed.

Methods
Normal, uninjured participants aged 2-17 years were enrolled in the study. Monofilament and static/moving two-point discrimination tests were performed bilaterally assessing the median, ulnar, and radial nerves. Three trials were performed for each test in each nerve distribution and the child was considered to be able to perform the test if they answered correctly all three times. Statistical analysis was performed utilizing univariable linear regression, Welch’s t-test, and one-way ANOVA.

Results
396 hands were tested utilizing the Semmes-Weinstein monofilament and static/moving two-point discrimination tests. For the monofilament test, 27% of 3 year olds, 83% of 4 year olds, and all participants 5 years of age and older were capable of performing the monofilament test. There was a significant difference in the capability rate between 3 and 4 year olds (p = 0.012). The ANOVA and linear regression analysis showed no correlation between advancing age and performance scores for any of the nerve distributions. The ulnar and median nerve distributions are more sensitive than the radial nerve distribution (p < 0.001). Hand dominance does not affect monofilament scores except in the radial nerve distribution where patients showed better threshold testing in the dominant hand (p = .028).

For two-point discrimination tests, 33% of 4 year olds, 61% of 5 year olds, 88% of 6 year olds, 95% of 7 and 8 year olds, and all participants 9 years and older were capable of performing the static/moving two-point discrimination tests. There was a significant difference in the capability rate between 5 and 6 year olds (p = 0.046). The linear regression analysis showed no correlation between advancing age and performance scores for any of the nerve distributions. Children are the most sensitive in the median, then ulnar, and then radial nerve distributions (p < .001). Hand dominance does not affect two-point discrimination scores except in the radial nerve distribution where patients showed better density testing in the dominant hand (p < .05). The average static/moving two-point discrimination scores were directly compared and children/adolescents can better discriminate between two moving points than static points (p < .001).

Conclusion
Objective testing of sensation can be reliably performed in children. Threshold testing utilizing a monofilament can be performed in children as young as 5 years, whereas density testing utilizing two point discrimination can be performed in children as young as 7 years.

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Realignment and Intramedullary Rodding of the Humerus and Forearm in Children with Osteogenesis Imperfecta: Effect on Fracture Rate

Sunday, October 23
9:52AM - 9:59AM
Moscone West, 2010

Purpose
Osteogenesis imperfecta (OI) is a genotypically and phenotypically heterogeneous group of inherited disorders characterized by brittle bones, fractures and skeletal deformity. Surgical intervention in the form of intramedullary rodding is indicated for the long bone segments of the extremities to manage deformity and help treat recurrent fractures. Historically, the focus of long bone surgery for children with OI has been the lower extremity. A recent pair of studies has described the functional improvements in children with OI undergoing upper extremity procedures. The purpose of this study is to report on the impact on fracture rate of intramedullary rodding of the humerus and forearm in children with OI.

Methods
This is a retrospective chart review of 24 long bone segments in 13 children with OI who have undergone realignment and intramedullary rodding of the humerus and forearm (radius, ulna or both bones) from 2005-2016 at an average age of 8.6 years (standard deviation (SD) 4.5). Thirteen humeri and 8 forearms have been included. Intramedullary implants included Kirschner wires (9 segments), Fassier-Duval rods (4 segments), male component of the Fassier-Duval rod (4 segments), flexible nails (5 segments), a flexible nail and Kirschner wire (1 forearm) and strut allograft (1 humerus). Mean follow-up time was 46.8 months (SD 32.53). Fractures included in the study were those that were documented in the charts even though many fractures in this patient population go unreported. In utero fractures and those diagnosed at birth were not included. The denominator (in years) for the preoperative fracture rate included the number of years from the first fracture of the operative long bone segment to the date of rodding (lowest denominator used was one year). Revisions of the upper extremity roddings were not included in the fracture analysis.

Results
The average number of preoperative fractures for each segment that underwent realignment and rodding was 3.8 (SD 3.0) and the average number of postoperative fractures for each segment that underwent realignment and rodding was 0.5 (SD 0.7) (p < .01). The average preoperative fracture rate was 0.9 fractures/year (SD 0.5) and the average postoperative fracture rate was 0.1 fractures/year (SD 0.2) (p < .01). Four upper extremity segments required revision at an average of 23 months postoperatively. One patient with mild OI underwent elective removal of forearm flexible nails.

Conclusion
Realignment and rodding of the humerus and forearm in children with OI significantly reduces the number of fractures as well as the rate of fracture of the bone segment that is rodded. This data, along with a recent pair of reports of the functional outcomes of upper extremity rodding in the OI population, may help OI patients and families seek treatment for their upper extremities and help guide their expectations.

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Are There Patient Characteristics Associated with an Increased Risk for Open Reduction in the Treatment of Supracondylar Humerus Fractures?

Sunday, October 23
9:59AM - 10:06AM
Moscone West, 2010

Purpose: Current recommendations for treating supracondylar humerus (SCH) fractures include closed reduction and percutaneous pinning. However, if difficulties with closed reduction arise, open reduction may be utilized. The purpose of this study is to identify the patient and treatment characteristics more commonly associated with open versus closed reduction of SCH fractures.
Methods: A retrospective chart review of patients treated for SCH fractures from 2010 to 2014 at a tertiary care children’s hospital was performed. Patients were excluded for type I or II SCH fractures. There were 207 patients who met inclusion criteria with 73.4% (152/207) classified as type III SCH fractures and 26.6% (55/207) as type IV. Mean age at admission was 5.2 years (range 0.4-13.0).
Results: A total of 191 (92.3%) closed and 16 (7.7%) open reductions had complete records that could be studied. A number of different physical exam and fracture characteristics were found to positively correlate with open reduction. Skin puckering was found in 5.1% (9/178) of closed reductions and 35.7% (5/14) of open (p < 0.001). Correlated vascular exam findings included no palpable pulse (closed=13.8% [26/188], open=81.2% [13/16]) (p < 0.001), lack of perfusion (closed=0.6% [1/175], open=6.7% [1/15]) (p=0.026), cool subjective temperature of the ipsilateral hand (closed=0.6% [1/174], open=7.7% [1/13]) (p=0.016), and >2 second capillary refill (closed=1.3% [2/151], open=20.0% [2/10]) (p < 0.001). Exam correlations also included findings of nerve palsy (closed=22.6% [43/190], open=93.7% [15/16]) (p < 0.001) as well as the specific palsy types median (p < 0.001), radial (p=0.036) and AIN (p < 0.001). Gartland classification type IV fractures were more likely to require open reductions than type III fractures (closed=24.6% [47/191], open=50.0% [8/16]) (p=0.027). A significant difference was found in the time to OR for closed (mean=14.3±17.6 hrs) versus open (mean=25.4±34.8 hrs) reduction. No significant difference was found in average age (closed=5.2±2.5 years, open=5.8±1.2 years, p=0.077) or amount of flexion type fractures (closed=1.0% [2/191], open=6.2% [1/16], p=0.094) in closed versus open reductions.
Conclusion: Positive associations with open reduction included Gartland type IV fracture, longer time to OR, and higher severity of physical exam findings such as skin puckering, compromised vascular supply, and nerve palsies.

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Orif for the Irreducible Supracondylar Humerus Fracture Varies by Surgeon, Not Years of Experience

Sunday, October 23
10:06AM - 10:13AM
Moscone West, 2010

Purpose: Closed reduction and percutaneous pinning (CRPP) is the mainstay of operative treatment of supracondylar humerus (SCH) fractures, and is the most common operation in pediatric orthopaedic surgery. Open reduction and internal fixation (ORIF) is associated with increased risks of infection, scar formation, and iatrogenic neurovascular injury, but must sometimes be performed when there is neurovascular compromise, or in rare circumstances when the surgeon cannot obtain a satisfactory closed reduction. Although there has been much recent attention surrounding management of the SCH fracture with neurovascular compromise, there is no published study to date specifically focused on ORIF for the irreducible SCH fracture. The purpose of this study was to determine the rate of ORIF in the operative management of SCH fractures and to identify surgeon-dependent variability with failure to achieve satisfactory closed reduction.

Methods: We performed a retrospective, descriptive cohort study of consecutive patients treated operatively for closed, extension-type SCH fractures at a large, tertiary pediatric trauma center over a 16-year period. Data collected included patient demographics, preoperative, and peri-operative clinical characteristics. A one-way ANOVA was performed to compare the effect of surgeon on the rate of inability to achieve satisfactory closed reduction. A univariate logistic regression model was used to analyze if surgeon experience, as measured by years in practice at the time of surgery, correlated with rate of ORIF performed specifically for the inability to achieve closed reduction.

Results: Of the 2,647 patients (47.9% female, mean age 5.8 ± 2.5 years) who underwent surgical management for a closed, extension-type SCH fracture, ORIF was performed in 50 cases (1.90%). In 41 of these 50 cases (82.0%), ORIF was performed after failure to achieve a satisfactory closed reduction (41/2,647; 1.54%). Anterior (56.1%), medial (24.4%), lateral (14.6%), and posterior-based (4.9%) surgical approaches were utilized. The surgical management of the SCH fractures was performed by 12 different attending pediatric orthopaedic surgeons with practice experience ranging from two weeks to 32.8 years. A one-way analysis of variance revealed significant differences between individual surgeons’ rate of ORIF performed due to failed closed reduction, [F(11, 2604)=2.61, p=0.003]. Among 11 surgeons with a minimum of 50 cases, mean surgeon rate of ORIF was 2.1% (SD ± 2.1, Range, 0-7.1) (Figure 1). Regression analysis showed no association between surgeon experience and the rate of performing ORIF (p=0.27).

Conclusions: In this 16-year study of 2,647 surgically treated SCH fractures, we found that ORIF for failed closed reduction was needed rarely, but the individual surgeon rate of needing ORIF varied significantly. Surprisingly, failure to achieve closed reduction did not correlate with surgeon experience.

Figure 1

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Assessment of Current Epidemiology and Risk Factors Surrounding Brachial Plexus Birth Palsy

Sunday, October 23
10:13AM - 10:20AM
Moscone West, 2010

Purpose:
Brachial plexus birth palsy (BPBP) is quite common in the United States, with a reported incidence of 1.5 per 1,000 live births. However, this rate has been shown to be decreasing. With the current increasing rate of Cesarean delivery, it is unknown what the current incidence of BPBP is. Additionally, more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known and unknown risk factors, and evaluate the length of stay (LOS) and costs of children with an associated BPBP injury.

Methods:
Data from the 1997-2012 Kids’ Inpatient Database data sets were evaluated utilizing ICD-9 codes to identify patients with a BPBP injury and various risk factors. Additionally, patient demographics and hospital characteristics were assessed. Evaluation of LOS data and cost was also performed. Multivariate logistic regression analysis was utilized to assess the association of BPBP with its known and unknown risk factors, adjusting for sociodemographic and hospital characteristics.

Results:
The incidence of BPBP has steadily decreased from 1997-2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number one risk factor for the development of a BPBP injury, with an Odds Ratio of 166.01. Hypotonia is a newly recognized risk factor for the development of BPBP with an Odds Ratio of 1.93. Fifty-five percent of infants with BPBP still have no known risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury compared to those without one and the hospital stay costs are approximately 40% higher.

Conclusion:
The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the number one risk factor for sustaining a BPBP injury. The increasing incidence of cesarean delivery likely corresponds to the decreasing incidence of BPBP injury. Children with a BPBP injury have longer length of stays and hospital costs compared to children without a BPBP injury.

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Influence of Insurance Type on the Access to Pediatric Care for Children with Distal Radius Torus Fractures

Sunday, October 23
10:20AM - 10:27AM
Moscone West, 2010

Background: Previous literature has demonstrated that pediatric orthopedic patients with private insurance have less difficulty obtaining appointments than those with Medicaid. Not all injuries of an orthopedic nature, however, require specialist care. This study evaluated the willingness of pediatricians to provide care for a distal radius torus fracture and whether or not the patient’s insurance status influenced the decision to provide care.

Methods: 99 pediatric primary care offices were randomly selected from two regions in Florida. Each office was contacted twice, 2-3 months apart, and presented with a fictionalized account of a patient that had suffered a torus (“buckle”) fracture of the distal radius. In the first call, the patient was presented as having private insurance, and in the second call as having Medicaid insurance. If the patient was denied an appointment, the reason was recorded.

Results: Of the 99 offices, 100% were willing to treat the patient’s injury if the child had private insurance, compared to 76% if the child had Medicaid. All Medicaid patient refusals were based on the insurance status of the patient. No office refused to see the patient due to the nature of the injury. 94% of offices in South Florida were willing to see the Medicaid patient, compared to 58% in Central Florida. These differences were statistically significant (P < .0001).

Conclusions: Our findings indicate that most pediatricians are willing to treat a minor orthopedic injury, such as a torus fracture, provided the patient has the proper insurance. This information is valuable for emergency departments who might otherwise refer all of these injuries to tertiary pediatric orthopedic centers. Differences among regions, such as median household income and the number of publicly insured patients in the area, may have influenced pediatricians’ willingness to provide an appointment to Medicaid patients. The nature of the injury, however, did not affect the pediatrician’s willingness to manage the patient.

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Comparison of Percutaneous Reduction and Pin Fixation in Chronic and Acute Pediatric Mallet Fractures

Sunday, October 23
10:27AM - 10:34AM
Moscone West, 2010

Introduction
Although pediatric mallet fractures are more common than adult fractures, no techniques have focused on surgical fixation of pediatric mallet fractures. This study aims to describe the technique and results of percutaneous reduction and fixation in acute and chronic pediatric mallet fractures.

Material and Methods
This is a retrospective review of 59 pediatric mallet fractures treated with percutaneous wire fixation from 2007-2014; 43 were acute fractures and 16 were chronic (>4 weeks from injury). Surgical technique was identical for all fractures; (1)levering the dorsal fragment into its anatomical bed with a percutaneous towel clip; (2)percutanously transfixing the DIP joint in slight hyperextension; (3)placing 2 percutaneous K-wires, one radial and one ulnar, from the dorsal epiphyseal fragment to the volar metaphyseal cortex. Outcomes were defined by the Crawford classification.

Results
Average age was 14.6 years (range, 11 to 18). Mean time from injury to surgery was 15.3 days in the acute group and 51.4 days in the chronic group. 8 patients did not have radiographs at time of final follow-up. Mean joint surface involvement was 50.6% of the articular base with a mean of 2.11mm of articular gap (acute fractures 1.93mm, chronic fractures 2.58 mm, p < 0.007). Average pre-operative extensor lag was 25.1 degrees. Average operative time was 33 minutes for acute fractures and 39 minutes for chronic fractures. Mean length of follow-up was 73.8 days. At final follow-up, all patients healed with an articular gap of 0.16mm in the acute group and 0.59mm in the chronic group (p=0.49) with no nonunions or volar subluxations. All patients but 8 (5 acute, 3 chronic) achieved full extension with an average extensor lag of 1.1 deg for the entire cohort. No patient had greater than 10degree extensor lag at final follow-up. All patients achieved full active flexion of 90degrees at final follow-up. In the acute group, the Crawford classification was excellent in 87% (33/38), good in 13% (5/38). In the chronic group, results were excellent in 77% (10/13), good in 23% (3/13) (p>0.05). There were no fair or poor outcomes in either group. A clinical dorsal bump was noted in 15% of patients (16% in the acute group, 13% in the chronic group, p>0.05). There were no infections, wire breakages, nail deformities, or unplanned returns to surgery.

Conclusion
This percutaneous surgical technique to treat pediatric mallet fractures achieves favorable clinical and radiographic results with minimal complications, even in chronic fractures. Results are better than reported for adult mallet fractures.

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Flexion Supracondylar Humerus Fractures: Ulnar Nerve Deficit Is a Risk for Open Reduction

Sunday, October 23
10:34AM - 10:41AM
Moscone West, 2010

Purpose: The vast majority of pediatric supracondylar humerus fractures (SCFxs) can be treated with closed reduction and percutaneous pinning. Usually, the need for open reduction and internal fixation (ORIF) is not known until the child is anesthetized and positioned and either closed reduction fails, or distal ischemia persists; then urgently, a new set-up or additional equipment is needed for open reduction. For this reason, any injury characteristics that predict the need for open reduction are valuable for pre-operative planning. A few small series have suggested that flexion SCFXs are more likely to require open reduction. From a large consecutive series of SCFxs, we investigated the incidence of flexion SCFxs, the rate of ORIF in flexion SCFxs, and predictors of the need to perform open reduction.

Methods: We developed a database of consecutive operative pediatric SCFxs at a single major pediatric trauma center from 2000 to 2015. Data included age, mechanism of injury, surgeon, associated injuries (including neurovascular), treatment, and fracture type. We reviewed the radiographs of all fractures reported as flexion SCFxs to confirm the pattern. The risk of ORIF associated with flexion-type fracture pattern and ulnar nerve injury at presentation were each assessed by odds ratio (OR) and their corresponding 95% confidence interval (CI).

Results: Of the 2,783 consecutive pediatric SCFxs, 95 were flexion-type (3.4%). Ulnar nerve injury was noted in 10/95 (10.5%). Open injuries were identified at presentation in 3/95 (3.2%) of cases. Among closed fractures, 21/92 (22.8%) flexion-type fractures required open reduction compared to 50/2647 (1.9%) extension-type SCFxs (OR = 15.4, CI, 8.8-27.0, P < 0.001). Open reduction was performed in 6/10 (60.0%) closed, flexion fractures with ulnar nerve injury, compared to 15/82 (18.3%) flexion SCFxs without ulnar nerve injury (OR = 6.7, CI, 1.7-26.7, P=0.003).

Conclusion: In this largest reported series of flexion SCFXs, we found that the flexion pattern is correlated with a 15.4-fold increase in the odds of requiring an open reduction. The presence of an ulnar nerve deficit in those flexion pattern fractures adds a 6.7-fold risk of open reduction compared to flexion SCFxs without signs of ulnar nerve injury.

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One Visit-one Brace: Patient and Parent Satisfaction After Treatment for Pediatric Distal Radius Buckle Fractures

Sunday, October 23
10:41AM - 10:48AM
Moscone West, 2010

Purpose: Multiple previously published studies have shown the efficacy of brace treatment for distal radius buckle fractures. There is also literature to support the fact that these inherently stable injuries do not require additional radiographic imaging. However, no study has looked at a treatment protocol combining both of these aspects. We aim to determine if the treatment of pediatric buckle fractures of the distal radius, with a removable brace and no further physician follow-up or imaging after the initial visit, is a safe and satisfactory therapeutic protocol.

METHODS: 42 consecutive patients with a diagnosis of distal forearm buckle fracture seen by a single practicing pediatric orthopaedic surgeon were recruited to participate in this IRB approved study. 2 patients refused participation, leaving 40 patients treated with a standard protocol as follows: immobilization with a removable wrist brace, worn for a prescribed time period; no additional imaging or clinical follow-up. Two telephone surveys were administered to each of the 40 patients. The first call was made within 1 week of the designated brace-removal date to determine the exact date the brace was discontinued. The second call was made 5-10 months post-injury to determine patient outcomes and parent satisfaction after the treatment via a series of 17 questions.

RESULTS: 100% of patients were reached for the initial phone call. 36/40 patients (90%) were available to answer the second phone survey questionnaire. There were no complications, including re-fracture or residual pain, following the treatment. Only 4/36 (11%) required any type of pain medication, and all took only over-the-counter ibuprofen or acetaminophen. No patients required narcotics for pain control. 100% of parents said they would choose to have the same treatment again, as 68% would have had to miss work and 78% would have had to pull the child out of school if they had been required to attend a follow-up appointment.

CONCLUSION: Treatment of distal forearm buckle fractures with a removable brace and no follow-up visit results in both good patient outcomes and parental satisfaction. This treatment method is both directly and indirectly cost-effective, prevents additional radiation exposure, and increases access to care as it leaves additional appointments available in the busy pediatric orthopaedic practice.

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Management of Pediatric Grade 1 Open Forearm Fractures

Sunday, October 23
10:48AM - 10:55AM
Moscone West, 2010

Purpose: There is recent controversy regarding the treatment of grade one open fractures. Treatment modalities range from a single dose of IV antibiotics in an emergency room setting and local wound care without hospital admission to formal irrigation and debridement in the operating room. Historically, it has been recommended that all open fractures be taken to the operating room for formal surgical irrigation and debridement. Several recent studies have emerged that support non-operative and even outpatient management of such injuries. The purpose of this study is to analyze the treatment, and outcome of pediatric grade 1 open forearm fractures at a single level 1 trauma institution.

Methods: After IRB approval, ICD-9 codes were used to identify potential patients. Inclusion criteria was defined as patients between ages 1-17, grade 1 open fracture of radius or ulna, and at least 6 weeks of follow-up. Twenty-three patients met the inclusion criteria for analysis. Charts were reviewed for fracture type, mechanism of injury, fracture and wound management, antibiotic course, and outcome.

Results: All patients sustained their injuries from a low-energy mechanism. Closed reduction of the fracture under conscious sedation and cast application was performed in 21 cases. Eleven patients were sent home from the ED, 7 were admitted with 24 hours of IV antibiotics and discharged the next day and 3 patients did not obtain adequate correction in the ED, and were admitted for operative management. All three patients received at least 24 hours of IV antibiotics and were discharged within 48 hours of the OR. These 21 patients received an additional 7 days of PO antibiotics.
Two patients underwent immediate operative management in the OR. One underwent wound irrigation, closed reduction and cast application, and was discharged after 24 hours of IV antibiotics. The second patient underwent formal wound incision, exploration, irrigation and debridement, closed reduction of the fracture and cast application. The patient was discharged after 24 hours of IV antibiotics. Both patients received an additional week of PO antibiotics.
There were zero reported infections in any patient regardless of treatment. There were no non-unions, malunions, wound healing issues or issues related to anesthesia. There were 3 loss of reduction occurring 1-2 weeks post-injury. All 3 of these patients underwent operative fixation without additional treatment of the open wounds and went on to heal their fractures without further complication.

Conclusion: In summary, this study illustrates the management of grade 1 open forearm fractures in children at a single center. There were no reported infections in any of the patients regardless of treatment. A prospective, randomized trial to compare out-patient treatment to non-operative inpatient treatment would be beneficial in assessing safety and efficacy of these treatment modalities.

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Outcomes of Emergency Room Closed Reduction vs in Situ Splinting in the Treatment of Pediatric Supracondylar Humerus Fractures

Sunday, October 23
10:55AM - 11:02AM
Moscone West, 2010

Purpose: Supracondylar humerus fractures are among the most common surgically treated pediatric fractures. Displaced supracondylar fractures are generally treated with open or closed reduction and percutaneous pinning. Multiple attempts at reduction may increase the risk of neuropraxia, elbow stiffness, myositis ossificans, and anesthetic complication. Previously, patients presenting to our institution with a displaced fracture underwent a closed reduction in the emergency department (ED) prior to repeat closed reduction and pinning in the operating room (OR). Currently, patients have been managed with in situ splinting in the ED until closed reduction and pinning are attempted in the OR. The purpose of this study is to investigate if there are clinical or radiographic outcome differences between these two management methods.

Methods: This retrospective case-control study included patients with supracondylar fractures from 2008-2014. Inclusion criteria were based on age 1-10 years and diagnosis of Gartland type 2 and type 3 fractures. Cases of polytrauma were excluded. Patients were separated into two groups depending on whether or not closed reduction was performed in the ED. All patients proceeded to surgery. Study outcomes were determined clinically and radiographically. The Fisher’s exact test was used for categorical variables and the Wilcoxon rank sums tests for continuous variables.

Results: 123 patients were included, 89 with reduction in the ED and 34 without. There was no significant difference between the groups related to BMI, age, sex, race, preoperative neurovascular insult, mechanism of injury, fracture classification, total OR time, number of pins used, or postoperative radiographic parameters (Baumann’s angle and anterior humeral line restoration). Patients managed without reduction in the ED had a lower average delay from ED to OR compared to those treated with reduction (15 hours vs. 22 hours, p=0.002) and a shorter hospital length of stay (35 hours vs. 40 hours, p=0.007).

Conclusion: There was no difference in clinical or radiographic outcomes between patients with Type 2 or Type 3 supracondylar fractures treated initially with or without closed reduction in the ED. Patients treated without ED reduction were taken to the OR sooner and remained in the hospital for a shorter period of time.

Significance: Patients undergoing closed reduction in the ED were exposed to an additional session of anesthesia which immediate splinting can forego. This exposure can be avoided without increasing the risk of postoperative complications or suboptimal outcomes.

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In-office Removal of Pediatric Elbow Pins: Increased Value in Orthopaedic Care

Sunday, October 23
11:02AM - 11:09AM
Moscone West, 2010

Introduction:
Elbow fractures are among the most common operative orthopaedic injuries in the pediatric population, with an incidence of 308/10,000 annually. Percutaneous pinning is a common technique for pediatric elbow fractures. Due to the small risk of infection, some surgeons choose to bury these pins, while others leave the pins exposed and remove them in the clinic setting. Burying the pins requires a second operation and has a significant economic effect on the patient and the health care system. To our knowledge, there has never been an analysis of the charges associated with the management of operative pediatric elbow fractures.
Purpose:
The purpose of this study is to compare the charges related to removing buried pins in the operating room versus removing exposed pins in the office.
Methods:
All pediatric elbow fractures requiring operative fixation were reviewed from the case log of a single fellowship trained pediatric orthopaedic surgeon to identify which patients required return trips to the operating room for pin removal. All patients were initially treated with smooth pins placed under sterile operating room conditions and standard clinical follow-up at one week, four weeks, and three months. In patients who had pins removed in clinic, the procedure was performed at four weeks during the routine clinic follow-up visit. In patients requiring pin removal in the operating room, same day outpatient surgery was performed at four weeks. Hospital and professional charges were reviewed and compared between the two groups.
Results:
Total professional charges were nearly identical for the initial procedures ($6,142 for patients who had in-office pin removal versus $7,439 for patients who underwent operative pin removal). The difference was due to slightly higher anesthesia and fluoroscopy charges. Patients who underwent operative pin removal incurred an additional $3,437 of professional charges and $6,850 of hospital charges, totaling $10,287, as a result of the second procedure to remove buried pins. Patients who had pins removed in the clinic had no additional charges, as these visits were included in the ninety-day postoperative global period. Total average charges were $17,869 for patients who had pins removed in the office versus $28,353 for patients requiring operative pin removal.
Conclusion:
Routine in-office removal of exposed pins in pediatric elbow fractures is cost-effective. In a health care system increasingly concerned with value (value = outcomes over costs), removing pins in clinic increases value, with an average cost savings of approximately $10,000 per case. Annually, the US health care system saves up to $6.5 billion with in-office removal of elbow pins.

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Kathy Abel, MSN, RN, APN

Nurse Practitioner
The Children's Hospital of Philadelphia
Marlton, NJ

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Christopher Arena, MD

Orthopaedic Surgery Resident
Penn State College of Medicine
Hershey, PA

Presentation(s):

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Graham Fedorak, MD

1. Shriners Hospitals for Children, Honolulu; 2. University of Hawaii, Dept of Surgery
Honolulu, Utah

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Kelly Flynn, Research Student

The Childrens Hospital of Philadelphia
Rose Valley, PA

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Kelly Flynn, Research Student

The Childrens Hospital of Philadelphia
Rose Valley, PA

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Jeanne Franzone, MD

Clinical Fellow - Pediatric Orthopaedic Surgery
Alfred I. duPont Hospital for Children
New York, NY

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Alex Gornitzky, MD

The Children's Hospital of Philadelphia
San Francisco, CA

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Liam Harris, BS

Children's Hospital Los Angeles
Los Angeles, California

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William Kesler, III., MD

Resident Physician
Penn State Hershey Department of Orthopaedics and Rehabilitation
Hershey, PA

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Megan Kuba, MD

University of Hawaii
Honolulu, HI

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Ryan Li, MD

Rainbow Babies and Children's Hospital, Case Western Reserve University
Cleveland, OH

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Haley Merrill, MD

Orthopaedic Surgery Fellow
Orthopaedic Foot and Ankle Center of DC
Fairfax, VA

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William Morris, MD

Orthopaedic Surgery Resident
Case Western Reserve University
Cleveland, Ohio

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William Morris, MD

Orthopaedic Surgery Resident
Case Western Reserve University
Cleveland, Ohio

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Harrison Potak, BS/BA

Medical Student
University of Central Florida College of Medicine
Orlando, FL

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Stephanie Pun, MD

Director of The Hip Preservation Program
Stanford Children's Health
Stanford University School of Medicine
Stanford, CA

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Manoj Reddy, MD

Orthopaedic Surgery Resident
The University of Chicago
Chicago, IL

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Mathew Schur, BA

Children's Hospital Los Angeles
Beverly Hills, CA

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Joseph Yellin, MD

The Children's Hospital of Philadelphia
Philadelphia, PA

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Keith Baldwin, MD, MPH

The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Daniel DeRosa, DO

Tripler Army Medical Center
Honolulu, HI

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Rachel Goldstein, MD, MPH

Children's Hospital Los Angeles
Los Angeles, California

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Rachel Goldstein, MD, MPH

Children's Hospital Los Angeles
Los Angeles, California

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Heath Gould

Case Western Reserve University
Cleveland, OH

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Christine Ho, MD

Associate Professor, UTSW
Texas Scottish Rite Hospital for Children
Dallas, Maryland

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John Holbert, B.S.

Medical Student
Penn State College of Medicine
Hershey, PA

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Christopher Iobst, MD

Nemours Children's Hospital, Orlando, Florida
Orlando, FL

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Byron Izuka, MD

University of Hawaii
Aiea, HI

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Timothy Lancaster, BS

University of Maryland School of Medicine
Timonium, MD

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Kelly Leddy, MHS

The Children's Hospital of Philadelphia
Philadelphia, PA

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Christina Master, MD, CAQSM

Associate Program Director, Pediatric Primary Care Sports Medicine Fellowship Program
The Childrens Hospital of Philadephia
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Charles Mehlman, DO, MPH

University of Cincinnati College of Medicine
Cincinnati, Ohio

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Michael Merz, MD

Boston Children's Hospital
Boston, MD

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Ashley Olson, MD

Cohen Children's Medical Center
New Hyde Park, NY

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Kenneth Rogers, PhD, ATC

Alfred I. duPont Hospital for Children
Wilmington, DE

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Apurva Shah, MD, MBA

The Children's Hospital of Philadelphia
Philadelphia, PA

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Luv Singh, MD

Resident Physician
University of Missouri Kansas City, Children's Mercy Hospital
Kansas city, MO

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Braden Tucker, BS

University Hospitals Case Medical Center
Cleveland, OH

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Drew Williamson, BS

University Hospitals Case Medical Center
Cleveland, OH

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Roger Yuh, MD

St. Luke's Bethlehem
Bethlehem, PA

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Jason Anari, MD

University of Pennsylvania
Philadelphia, PA

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Garrett Bowen, BS

Clinical Research Coordinator
Boston Children's Hospital
Boston, MA

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Amy Brough, HBSc

John A Burns School of Medicine, University of Hawaii
Honolulu, HI

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Paul Choi, MD

Children's Hospital Los Angeles
Los Angeles, CA

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John Chuo, MD

Attending Physician
Children's Hospital of Philadelphia
Perelman School of Medicine, University Of Pennsylvania
Philadelphia, Pennsylvania

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Joseph Drain, BS

University Hospitals Case Medical Center
Cleveland, OH

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Kelly Flynn, Research Student

The Childrens Hospital of Philadelphia
Rose Valley, PA

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Eric Fornari, MD

Montefiore Medical Center
Bronx, New York

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Krister Freese, MD

Denver Children's Hospital
Aurora, CO

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Jeremy Gebhart, MD

Case Western Reserve University
Cleveland, OH

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Ian Greenberg, BS

Children's Mercy Hospital
Kansas City, MO

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Dennis Kramer, MD

Boston Children's Hospital
Boston, MA

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Raymond Liu, MD

Rainbow Babies and Children's Hospital
Case Western Reserve University
Cleveland, Ohio

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Christina McGreal, MSN

Alfred I. duPont Hospital for Children
Wilmington, DE

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Charles Price, MD

University of Central Florida College of Medicine
Orlando, Florida

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Alexa Vetere, PA-C

Cohen Children's Medical Center
New Hyde Park, NY

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Katherine Xie, BS

Case Western Reserve University
Cleveland, OH

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Jun Ying, PhD

University of Cincinnati College of Medicine
Cincinnati, OH

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Michael Bober, MD, PhD

Alfred I. duPont Hospital for Children
Wilmington, DE

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John Flynn, MD

Chief of Orthopaedic Surgery
Children's Hospital of Philadelphia
University of Pennsylvania
Philadelphia, Pennsylvania

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Cody Fowers, BS

Case Western Reserve University
Cleveland, OH

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Andreas Hingsammer, MD

University of Zurich
Zurich, Switzerland

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Mininder Kocher, MD, MPH

Boston Children's Hospital
Boston, Massachusetts

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Kelly Leddy, MHS

The Children's Hospital of Philadelphia
Philadelphia, PA

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Raymond Liu, MD

Rainbow Babies and Children's Hospital
Case Western Reserve University
Cleveland, Ohio

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Robin Miyamoto, PHD

Director of Medical Research
Shriners Hospitals for Children, Honolulu
Honolulu, HI

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Alexander Neuwirth, MD

University of Pennsylvania
Philadelphia, PA

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Donna Pacicca, MD

Pediatric Orthopaedic Surgeon
Children's Mercy Hospital
Kansas City, MO

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Rachel Porter, PA-C

Cohen Children's Medical Center
New Hyde Park, NY

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Todd Rubin, MD

Montefiore Medical Center
Bronx, NY

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David Wang, BS

University Hospitals Case Medical Center
Cleveland, OH

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Lawrence Wells, MD

The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Jon-Paul DiMauro, MD

Cohen Children's Medical Center
New Hyde Park, NY

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John Flynn, MD

Chief of Orthopaedic Surgery
Children's Hospital of Philadelphia
University of Pennsylvania
Philadelphia, Pennsylvania

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Theodore Ganley, MD

The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Theodore Ganley, MD

The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Allison Gilmore, MD

University Hospitals Case Medical Center
Cleveland, OH

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Raymond Liu, MD

Rainbow Babies and Children's Hospital
Case Western Reserve University
Cleveland, Ohio

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