1ST ANNUAL PEDIATRIC ORTHOPEDIC
Surgical Techniques Lab 30 September - 1 October 2016 Memphis, Tennessee, USA
Table of Contents Introduction 1 Upper Extremity and Trauma
Closed reductions and casting Supracondylar humerus fractures Lateral epicondyle fractures Medial epicondyle fractures Forearm fractures Lab session
2 2 3 3 4 4
Hip and Lower Extremity - Infection and Trauma
Septic hip arthrotomy Femoral fractures Fixation techniques in tibia fractures Foot fractures Open discussion: Vitamin D levels in children with fractures Lab session
5 5 5 6 6 6
Hip Osteotomies / Deformity / Foot Deformity analysis Hip osteotomies Slipped capital femoral epicondilytis (SCFE)/hip dislocation Limb length discrepancy Clubfoot Lab session
Sports – Knee Principles of pediatric sports surgery “Kids aren’t small adults” Pediatric knee injuries (discoid meniscus, meniscus tears, osteochondritis dissecans) Pediatric anterior cruciate ligament (ACL)/tibial spine Patella femoral realignment Lab session
Spine Osteotomy types Pedicle screws, sacral and pelvic fixation Lab session Growth-friendly surgery Correction strategies for adolescent idiopathic scoliosis (AIS)
7 7 7 7 7 7 7
8 8 8 8 9 9
9 9 9 10 10 10
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
Introduction As a resident or fellow, getting experience in a new surgical field can be challenging. That’s why the 1st Annual Pediatric Orthopedic Surgical Techniques Lab (POST) in Memphis, Tennessee, was created — a course for senior residents and fellows who are looking to branch out into or have an interest in pediatric orthopedic surgery — the first one of its kind. For residents, fellows and young attending surgeons, hands-on, interactive learning is valuable. It is also a widely held belief that training on cadavers is beneficial for the teaching of surgical and operative skills, letting participants practice their skills in a safe environment. In this course, the learning environment is enhanced by world-class faculty who guide and mentor them. The POST Course was designed to meet the needs of the developing pediatric surgeon by combining cadaveric training, excellent bio-lab facilities and expert faculty at the Medical Education and Research Institute, to create a truly unique learning experience that focused on onlabel use of instrumentation and surgical techniques. The course variety included: • a series of short expert lectures presenting the rationale behind the techniques to be practiced in the subsequent lab • a round of open discussion • up to 10 hours of intensive, hands-on surgical lab guided by the faculty members.
With a low ratio of four participants to one expert surgeon — plus two specialist pediatric surgeons offering input to surgical techniques at the same time — participants were able to delve deep into learning. For upper and lower limb surgery, the labs were set up to allow for simultaneous bilateral procedures, thus four surgeons could work in parallel pairs, maximizing the time spent in the lab. Students were able to log 10+ hours of practical surgical training and, with lectures, up to 16.0 AMA PRA Category 1 CreditsTM. Dr. Todd Milbrandt (Mayo Clinic) and Dr. Jeffrey Sawyer (Campbell Clinic), leading experts in the field of pediatric orthopedic surgery, co-chaired the event and carefully hand-selected a group of expert faculty who are passionate about educating surgeons in this specialty. In a collegial atmosphere, the faculty drew on their personal experiences to provide participants with real-life tips and tricks. There are only so many things that you can learn in a text book, and only so many things you can learn through observation, but being at the forefront and gaining directed hands-on experience is a once-in-a-lifetime opportunity. As one attendee said:
“I had three operations on my bucket list, and I got to do all three of them today.”
Upper Extremity and Trauma Closed reductions and casting Participants started Day 1 learning from Dr. Kelly about closed reduction techniques and the importance of good casting, and tips for gaining experience in the removal of casts in order to avoid common cast burns and unnecessary cuts. Tips from the faculty: • Use casting simulators using sensors and saw bones for pressure monitoring • Keep good and bad casts as examples • Have someone hold the limb correctly • Run casting workshops • Give constructive feedback • Attend casting workshops • Use a pool-noodle to practice cutting off a cast Later in the program, participants acquired critical experience in casting and removal during the clubfoot casting workshop, in which some participants were able to use a cast saw for the very first time.
“We are never done learning, and we are always teaching.” — Dr. Kelly .
Derek Kelly, MD Associate Professor, The University of Tennessee Health Science Center UT-Campbell Clinic, Department of Orthopedic Surgery Dr. Kelly gained his degree in medicine from the University of Arkansas (2002), where he also went on to complete his residency. After a fellowship in pediatric orthopedics and scoliosis at the Texas Scottish Rite Hospital for Children in Dallas, he joined the staff of the Campbell Clinic (2008). Dr. Kelly specializes in pediatric orthopedic conditions and has a particular focus of Perthes Disease, being a member of the International Perthes Study Group.
Christine Ho, MD Staff Hand Surgeon, Texas Scottish Rite Hospital for Children, TX Dr. Ho studied medicine at the University of Texas Southwestern Medical School and completed an orthopedic residency at the University of Southern California, Department of Orthopedic Surgery. Dr. Ho completed her fellowships in pediatric orthopedics and scoliosis, and pediatric hand surgery, at the Texas Scottish Rite Hospital for Children.
Supracondylar humerus fractures “This course isn’t just about traditional didactic learning, it’s about teaching the practicalities of orthopedic surgery, such as OR setup,” Dr. Ho told participants, and that’s just what they received. Some highlights and tips from Dr. Ho’s presentation: • An optimized operating room set-up allowing for accurate radiographs, increased access to the affected structures and better visualization • Using a short plexiglass board instead of a long hand-table allows for better access to the elbow in a pediatric patient • In difficult closed reductions, the joystick technique technique using a 2.0mm smooth k-wire may be useful to assist in fragment reduction • Knowing when to perform an open reduction, particularly in flexion-type fractures • The rare occurrence of the easily missed transphyseal fractures in toddlers, the difficulties in diagnosis and its association with non-accidental trauma Participants also gained insight into maintaining proactive, open communication with the patient’s family.
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
“We seldom have the chance to gain hands-on experience - we watch demonstrations, watch videos and read books, but here we can really practice the techniques we have learned.” — A participant
Medial epicondyle fractures Dr. Edmonds followed with medial epicondyle fractures, demonstrating the need for a distal humerus axial radiograph to evaluate anterior displacement. “There are no reasons not to operate, even if closed reduction is effective,” surgeons were told, along with insight gleaned from Dr. Edmonds’ years of practice: the preference towards open reduction comes from seeing muscle-function deficits left by closed reduction, even when range of motion is restored.
Optimal operating room set-up for supracondylar humerus fracture reduction
Lateral epicondyle fractures Dr. Ritzman delved into the particular importance of imaging, giving participants the decision-making tools they’ll need to avoid inappropriate closed treatment or inadequate fixation. Pediatric orthopedic surgeons need to be ready and prepared to operate and pin if necessary. Dr. Ritzman presented recommendations for use of divergent pins and a washer to bring these points home in a practical way.
Distal humerus axial view to evaluate anterior displacement
Todd Ritzman, MD Pediatric Orthopedic Surgeon, Akron Children’s Hospital, Akron, OH Dr. Ritzman graduated from the Ohio State University College of Medicine before completing his residency in orthopedic surgery at the Cleveland Clinic. He completed a fellowship in pediatric orthopedics and scoliosis at the San Diego Children’s Hospital, before moving to the Akron Children’s Hospital.
Obtaining internal oblique radiographs, which show displacement 70% of the time, is critical to diagnosis. — Dr. Ritzman
Forearm fractures After reviewing standard techniques for using pins, plates and screws or intramedullary nails for forearm fractures, Dr. Ho covered the use of curved flexible nails. Tips for placing flexible nails: • Drill an opening hole 1 mm larger than the nail • The starting point is always a little more dorsal than you think at first • Be ready to attempt an open reduction if closed passage of a nail fails after three or four attempts • Consider burying pins • Fix the ulna first then the radius
“There are so many surgeons and so few participants - we can ask them anything we want, they are so approachable.” — A participant
Participants had the opportunity to see a selection of real-life cases, reinforcing the principles of fracture healing they’d learned — particularly demonstrated by the 6-month outcomes, which demonstrated the astounding remodeling capabilities of pediatric bone.
The washer can be clearly seen on this X-ray showing lateral condyle pinning
Over the course of 3 hours, participants were able to get handson experience with supracondylar pinning with a blind medial pin followed by an open approach, supracondylar ORIF with an anterior approach, lateral condyle approach and pinning versus screw fixation, medial epicondyle reduction, and pinning and nailing of the forearm. At all 8 lab stations, the participants were able to work bilaterally in simultaneous pairs, under the supervision of the expert faculty. This provided an opportunity to assess the differences between techniques, to observe hardware placement on fluoroscopy, and to receive immediate, constructive and corrective feedback. At Dr. Ho’s station, participants were actively encouraged to question their instrument choices, were asked to check the fluoroscopy themselves and give their opinions, and were made aware of feeling the differences between two different techniques. Dr. Ho gave her input into their choices and assessments, and commented “I know all this, I have done it all before” reinforcing how her expert experience can help the participants learn.
Eric Edmonds, MD Assistant Clinical Professor, University of California, San Diego, CA Pediatric Orthopedic Surgeon, Pediatric Orthopedic & Scoliosis Center, Rady Children’s Hospital, San Diego, CA Sports Medicine Program Consultant, Rady Children’s Hospital, San Diego, CA Dr. Edmonds qualified from the University of California Davis School of Medicine (2002), completed his residency in orthopedic surgery in the Carolinas Medical Center in Charlotte, NC, was a Pediatric Orthopedic and Scoliosis Fellow at the Rady Children’s Hospital in San Diego and, in 2008, successfully completed a travelling mini-fellowship in Sports Medicine, which took him to Boston, Philadelphia and back to San Diego. Clinical and research interests: • Youth sports medicine • Musculoskeletal trauma • Outcome studies for athletic shoulder, knee and ankle injuries • Outcome studies for fracture treatment
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
Hip and Lower Extremity Infection and Trauma Septic hip arthrotomy Dr. Frick instructed participants on how to correctly diagnose septic hip and the need for arthrotomy, and in the use of a systemsbased treatment approach. Some of the tips participants learned: • The only treatment for treating a pediatric patient with “pus under pressure” is to operate • It is essential to perform a clinical examination of the patient, regardless of the hour, to avoid increased morbidity through incorrect treatment of a missed septic hip • An MRI scan is essential before operating • Systems should be set up between orthopedic surgeons and the radiology department, to enable rapid access to MRI scans
“In 15–20% of the time, the MRI scan alters the treatment plan.” — Dr. Frick
Steve Frick, MD Surgeon-in-Chief and Chairman, Department of Orthopedics, Nemours Children’s Hospital, Orlando, FL. Professor of Orthopedic Surgery, University of Central Florida College of Medicine, FL. Clinical Professor, Department of Orthopedic Surgery, University of Florida.
Dr. Frick also warned that participants should be wary of leukemia in septic hip particularly in the presence of low hemoglobin.
Femoral fractures The main take-away message Dr. Novais gave participants was the importance of using the correct implants for the right fracture, particularly in diaphyseal fractures — a point he stressed with a clinical case presentation. Participants further learned about treatment algorithms in femoral neck fractures, with early surgical intervention being the best prevention against osteonecrosis of the femoral head.
Consultant, Nemours Children’s Hospital Muscular Dystrophy Association Clinic, Orlando, FL. Dr. Frick graduated with a medical degree from the Medical University of South Carolina (1991) and went on to complete a fellowship in orthopedic research and residency in orthopedic surgery at the Carolinas Medical Center in North Carolina. Dr. Frick also completed a fellowship in pediatric orthopedics at the Children’s Hospital San Diego and University of California, San Diego.
Fixation techniques in tibia fractures The goal of different fixation techniques for tibial fractures is achieving bone-healing, weight-bearing and acceptable alignment. Dr. Iobst presented the technique of cast-wedging as an alternative to hardware for achieving fracture reduction. Participants also got insights into the benefits of external fixators and hexapod frames, especially when there is an open wound, sparking discussion on the acceptable age for a locking proximal nail and the possibility of growth arrest through disruption of the physis. Members of the faculty shared their different age cut-off points and considerations, based on their personal experiences.
Eduardo Novais, MD Orthopedic Surgeon, Orthopedic Center and Children and Young Adult Hip Preservation Program, Boston Children’s Hospital, Boston, MA Dr. Novais gained his degree in medicine in Brazil at the Universidade Federal de Minas Gerais (1999), where he also completed his residency in orthopedic surgery. He went on to a number of fellowships, primarily in pediatric orthopedics in both Brazil and at the Campbell Clinic in Memphis, TN, and the University of Utah. Dr. Novais has also completed fellowships in musculoskeletal oncology at the Mayo Clinic Department of Orthopedic Surgery in Rochester, MN, and in adolescent and young adult hip-preservation surgery at the Boston Children’s Hospital, Harvard Combined Orthopedic Surgery. He was previously the director of the hip program at the Children’s Hospital Colorado.
It is important to use the correct fixation method first: a) status of elastic nailing after a secondary fall 10 days after placement, b) submuscular plating 6 weeks after placement, c) successful lateral trochanteric entry nail at 7 months after placement.
The difficulties in distinguishing between the normal variation of the foot bones and fractures can lead to misinterpretation. Mr. Monsell gave trainees the British view of open foot fractures, and how to develop a multidisciplinary approach involving mandatory attendance of both an orthopedic and a plastic surgeon. The importance of acquiring a CT scan for displaced articular fractures and the need to look proximally in a child with foot pain were reinforced, as was being aware of deliberate injury in under 18 month olds with foot fractures.
Difficult surgical approaches to joints were the theme of the hands-on session. Participants had the opportunity to work on the anterior approach for hip drainage, lateral approach to the hip, and triplane or tillaux approaches to the ankle. Participants benefited from getting experience in some surgeries that may be seldomly seen at their current level of clinical practice. Femoral bridge plating was a very practical session, where each participant was able to attempt screw placement, sometimes for the first time. The tibial flexible nail training enabled students to learn from the masters, taking home valuable tips for placement.
Open discussion: Vitamin D levels in children with fractures The day’s sessions closed with an open discussion on vitamin D levels in children with fractures, particularly when there is suspicion of metabolic fractures. The faculty were in agreement that good-quality vitamin D studies are needed.
“It is unknown whether most children are deficient or whether the “normal” vitamin D levels are no longer appropriate.” — A participant
Surgical Tip 1 Slightly bending the ski-tip of the flexible nail allows for easy insertion and smooth placement.
Fergal Monsell, MB BCh, MSc, PhD Christopher Iobst, MD Director, Center of Limb Lengthening and Reconstruction, Nationwide Children’s Hospital, Columbus, OH Dr. Iobst gained his medical degree from the Emory University School of Medicine, following which he undertook a residency at the Medical University of South Carolina. He went on to complete a fellowship in pediatric orthopedics at the Boston Children’s Hospital. Dr. Iobst’s specialty is in limb lengthening and reconstruction.
Consultant Orthopaedic Surgeon, Bristol Royal Hospital for Children, Bristol, UK Clinical Senior Lecturer, University of Bristol, UK Director, Avon Centre for Musculoskeletal Education Mr. Monsell qualified in medicine from the Welsh National School of Medicine, and completed further surgical training at the University of Manchester, UK. He undertook fellowship training at the Royal Alexandra Hospital for Children in Sydney, Australia. He has been a consultant orthopedic surgeon at a number of hospitals in the UK, including the Hospital for Sick Children, Great Ormond Street, and the National Orthopaedic Hospital in Stanmore. Mr. Monsell has a special focus on limb deformities and treating children with cerebral palsy.
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
Hip Osteotomies / Deformity / Foot Deformity analysis
Limb length discrepancy
Dr. Iobst led a speedy, interactive session on the principles of deformity analysis, with the aid of an X-ray handed out at the start of the session. After running through mechanical axis deviation and joint orientation lines, and an explanation of the angles involved in varus and valgus deformities, the students were able to identify the deformities (which were both proximal and distal) on the example X-ray.
Dr. Iobst gave a fast and informative session on leg-length discrepancy, his area of expertise. Key points of interest in this area of care: • Some patients are bothered by small discrepancies, while others are not bothered by large ones • No treatment is necessarily required unless there is documented regression or a functional problem • If treatment is indicated, it is important to understand if the discrepancy lies in the limb being too short or too long compared with the contralateral limb • Surgeons need to understand the anatomy of the physis, knowing where and how to perform an epiphysiodesis to achieve the desired results in case of a growing bone
“Consider the whole limb, and not just part of the limb, as there is often more than one deformity present.” — Dr. Iobst Hip osteotomies Dr. Novais gave a video presentation on pelvic osteotomies, focusing on the Bernese periacetabular osteotomy (PAO) technique and the numerous structures that are at risk during each of the cutting stages. Given the complicated nature of a PAO, it was particularly beneficial for all participants to be able to practice this complex surgical procedure in the lab.
Slipped capital femoral epicondilytis (SCFE)/Hip dislocation Dr. Kelly highlighted the importance of being able to know when an endocrinopathy may be behind SCFE. “Knee pain in a child is a hip problem unless otherwise diagnosed,” he said, stressing the need to take appropriate steps to achieve the correct diagnosis: • Image both hips • Obtain both lateral and AP radiographs, as 14% of SCFEs are missed on AP views • Further imaging, including MRI, CT and bone scans can be indicated in SCFE Dr. Kelly then focused on the risk of future slips, the role of prophylactic pinning and surgical techniques to treat SCFE, including numerous reconstructive procedures. The fact that SCFE treatment is a controversial topic, with many ways to treat it, became the focus of the open discussion. SCFE treatment is associated with steep learning curves, where the learning never ends. Furthermore, as SCFE patients can be at risk of avascular necrosis, timing is imperative.
“If you want to save the [femoral] head, get out of bed,” and perform early surgical intervention.
After cessation of growth, the options for limb lengthening include the archaic-but-functional external fixator, the more modern integrated fixator, or the intermedullary nail. Regardless of the method, the surgeon should not forget to address the underlying cause of the deformity and assess stability of joints and additional deformities. Given that leg-lengthening procedures occur over a number of years, patient and family selection to ensure maximal compliance is key.
Clubfoot Mr. Monsell relived the change in therapeutic approach that occurred during his career with the advent of the Ponsetti approach to casting. Although this casting technique has revolutionized club foot treatment, surgeons should still be aware of how to perform surgery in case of recurrence. The use of video instruction on the Ponsetti technique before the hands-on casting workshop enhanced the learning experience.
Lab session The lab session enabled participants to be actively taught the complex PAO technique by four expert PAO surgeons. Participants were able to rotate to other lab stations to practice SCFE screw placement, surgical hip dislocation and attempt a tibialis anterior tendon transfer. During the casting workshop, surgeons imparted their pearls of wisdom with regards to cast removal and molding. One student said that after trying out casting and cast removal, she felt confident enough to attempt cast removal on an infant, if under supervision. The set-up of the lab session allowed for more one-on-one teaching, especially beneficial for those interested in specific techniques.
— Dr. Frick
Sports – Knee Principles of pediatric sports surgery “Kids aren’t small adults”
Pediatric anterior cruciate ligament (ACL)/tibial spine
Dr. Edmonds reinforced the economic burden of sports-related injuries and conditions in pediatrics, which exceeds $2.5 billion in the U.S. per year. Children present numerous risk factors for sports-related musculoskeletal injuries: • Children have open growth plates and immature bones • They often specialize early in specific sports and have insufficient rest after injury • Children often concurrently participate in multiple sports, stressing different joints at the same time • Particularly in contact sports, they may be unevenly matched in size and strength
Because adult ACL reconstruction techniques put the physis at risk — leading to iatrogenic growth disruption — participants learned the specially developed pediatric techniques for physeal-sparing reconstruction, including combined intra-articular and extraarticular reconstruction of the ACL with an iliotibial band graft. A series of arthroscopic images accompanied the description, helping illustrate the key points. Dr. Murnaghan then presented his take on Dr. Allen Anderson’s published ACL reconstruction technique, in which both femoral and tibial tunnels, and the fixation for the quadruple hamstring graft are kept within the physis. Dr. Murnaghan then reviewed closed treatment options for type
Aside from the economic cost, injury can lead to lowered academic performance and depression, and increases the risk for osteoarthritis and obesity. Educating patients and families to avoid non-stop and simultaneous sport training, and promoting awareness of healthy sports practices, is critical to helping pediatric patients achieve life-long musculoskeletal health.
I and type II tibial spine fractures, mini-arthrotomy reductions in cases where arthroscopic reduction is not possible, and the use of screws and suture-fixation methods. The focus was on choosing the right fixation method based on the fragment, and the right technique based on the comfort level of the operating surgeon.
Pediatric knee injuries (discoid meniscus, meniscus tears, osteochondritis dissecans) Dr. Murnaghan stressed the importance of correct imaging — particularly the usefulness of coronal, sagittal and axial images on MRI — for diagnosing symptomatic discoid meniscus. Regarding treatment techniques, setting realistic expectations in discoid meniscus repair is important, as it is difficult to achieve a perfect knee. For osteochondritis dissecans (OCD), Dr. Murnaghan reinforced that correct diagnosis and thorough assessment of the lesion is important to determine the treatment: • Obtaining tunnel and skyline radiographs in addition to AP and lateral, and routinely using MRI allows for a better estimate of the size of the lesions • Juvenile OCD may be resolved non-operatively, with drilling or fixation • Non-operative treatment for adolescent OCD has limited use and drilling none, leaving fixation and salvage with augmentation as the treatment choice, dependent on arthroscopic classification
Lucas Murnaghan, MD, MEd Staff Physician in Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada Assistant Professor, Department of Surgery, University of Toronto, Toronto, Canada Dr. Murnaghan graduated with a degree in medicine at Queen’s University, Kingston, Ontario (2001), before completing his orthopedic residency at The University of British Columbia, followed by a fellowships in arthoscopy and athletic injuries. He then went on to undertake pediatric fellowships at the Royal Children’s Hospital in Melbourne, Australia, and at the Texas Scottish Rite Hospital for Children in Dallas, TX. Dr. Murnaghan focuses on pediatric and adolescent sports injuries, and is closely associated with the University of Toronto and Women’s College Hospital. Research interests: • Apert syndrome • Trauma • Developmental dysplasia of the hip
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
Patella femoral realignment Patellar instability is the most common knee disorder in children. Correct diagnosis is important, and surgeons should gain experience in repair techniques. Dr. Milbrandt presented a treatment algorithm for patellar instability and reviewed different medial patellofemoral ligament (MPFL) reconstruction techniques, which participants could then attempt in the subsequent lab session.
Lab session There were four knee stations, allowing intensive instruction for participants keen to practice MPFL and physeal-sparing ACL reconstructions using surgical instruments specifically designed for this purpose.
Todd Milbrandt, MD Orthopedic Surgeon, Pediatric and Adolescent Medicine Children’s Center, Mayo Clinic, Rochester, MN
Dr. Milbrandt graduated from the University of Virginia School of Medicine (1997) and went on to complete fellowships in pediatric orthopaedic surgery at the Texas Scottish Rite Hospital in Dallas. He also gained a Master of Science from the University of Virginia (2002). Clinical and research interests: • Pediatric orthopedics — scoliosis, clubfeet, cerebral palsy, trauma • Tissue engineering • Outcomes research He served on the board of the American Academy of Orthopedic Surgeons (AAOS) from 2013–2015, before which he was a chair, candidate, resident and fellow subcommittee for the AAOS (2011– 2013). He served on the board of the Pediatric Orthopaedic Society of North America (POSNA) from 2009–2011.
Osteotomy types Dr. Fletcher provided participants with detailed insights into spinal osteotomy types and a full understanding of their challenges, including the inevitability of a steep learning curve, and the high risk of complications with the rare and complex vertebral column resection. Success is dependent on: • Thorough training in Smith-Petersen and pedicle subtraction osteotomies • The support of an experienced surgeon • The advice of a neurosurgeon • Understanding and being competent in a variety of techniques in case an intraoperative change in procedure is required The presentation stimulated valuable discussion on the positives and pitfalls of osteotomy surgery.
Pedicle screws, sacral and selvic fixation Dr. Sawyer covered the essential of spinal fixation in relation to osteotomy. Surgeons must focus on expanding their skillsets and gaining knowledge of multiple techniques; being able to place pedicle screws, as well as hooks and wires in case of screw failure, is important. Maintaining a rigorous knowledge of anatomy was also encouraged.
Nicholas Fletcher, MD Assistant Professor of Orthopedic Surgery, Emory University School of Medicine, Atlanta, GA Fellowship Director, Emory Pediatric Orthopedics Co-director, Spine, Children’s Healthcare of Atlanta Dr. Fletcher attained his medical degree at the Vanderbilt University, Nashville, TN (2004) and completed his orthopedic residency at the Vanderbilt University Medical Center. After residency, Dr. Fletcher undertook a fellowship in pediatric orthopedics at the Texas Scottish Rite Hospital for Children in Dallas, TX, and went on to join Emory University School of Medicine (2010) as an orthopedic surgeon specializing in pediatric conditions, with a special focus on spine and hip conditions. He is a member of the Scoliosis Research Society education committee. Research interests: • Hip dysplasia • Development of a minimally invasive approach to surgical hip reconstruction Dr. Fletcher Additionally, is an active educator, overseeing the pediatric orthopedic education program at the Emory University School of Medicine.
Correction strategies for adolescent idiopathic scoliosis (AIS)
Growth-friendly surgery Dr. Sawyer highlighted that this is a changing field with rapidly advancing technology, and that early in situ fusion is associated with poor pulmonary outcomes. For new surgeons, it is essential to understand normal growth and spinal thoracic development, which are not linear. Treatment modalities for early-onset scoliosis included rib- and spine-based therapies, such as Vertical Expandable Prosthetic Titanium Rib (VEPTR), growing rods, magnetic-driven growth rods, and tethers. Because treatment can last longer than 10 years, surgeons should be familiar with all techniques across the continuum of a child’s care. Participants were also made aware of the possibility of thoracic insufficiency syndrome in early-onset
Dr. Ritzman led the participants through a comprehensive overview of correction strategies for adolescent idiopathic scoliosis and tips for undertaking surgery: • Rod strength is a factor in the success of surgery • High-density implants with high stiffness, and precontoured rods are needed The biomechanical benefits of ponte osteotomy for posterior release were also touched upon, before Dr. Ritzman took the participants through the rod rotation procedure with simultaneous dual rods with differential rod contour, which gives safe and gradual correction.
scoliosis. Dr. Sawyer closed by explaining the complexities of rod passage, the advantages of using a chest tube to assist in passing, and the need for awareness of intra-thoracic passage.
Lab session Participants were able to learn and practice facetectomies, insert pedicle screws, and attempt corrective derotation and reduction techniques for AIS. The session included a demonstration of magnetic growing rods. The participants did not shy away from training in complex spine surgery, attempting some rare surgeries in the safe setting of the bio-skills lab while under the watchful eye of experienced surgeons.
Jeffrey Sawyer, MD
Surgical Tip 2: To avoid accidental damage to the chest structures, make sure the tip of the hemostat is facing upwards during chest tube placement for rod passage.
Orthopedic Surgeon, Pediatric Orthopedic Fellowship University of Tennessee-Campbell Clinic, Memphis, TN
Dr. Sawyer received his medical degree from the University of Rochester in 1993. His orthopedic residency was undertaken at the University of Pennsylvania hospital. He is a member of the American Academy of Orthopedic Surgeons and Pediatric Orthopaedic Society of North America, as well as the Scoliosis Research Society and American Academy for Cerebral Palsy and Developmental Medicine. He currently serves on the editorial board of the American Journal of Orthopedics.
“The knowledge of multiple techniques [for spinal osteotomy and fixation] is essential.”
— Dr. Sawyer
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
“It was amazing to see the learning happening — they are drinking from the fountain of knowledge.” — Dr. Milbrandt
Residents and fellows who attend the Annual Pediatric Orthopedic Surgical Techniques Lab receive the full breadth of education: instruction and learning steeped in real-life perspectives, and practical lab work that lets them gain hands-on experience. But more than that, it’s all done in an atmosphere that allows for open discussion without the classical hierarchy of teaching.
“Trainees benefit from the fellowship of experience.”
— Dr. Ho
OrthoPediatrics was founded to focus exclusively on pediatric orthopedics, and is committed to the cause of improving the lives of children with orthopedic conditions. Education is one of the four pillars of OrthoPediatrics, and we’d like to invite you to expand your surgical horizons at the 2nd Annual Pediatric Orthopedic Surgical Techniques Lab in 2017: • Learn from experts who are innovative thought leaders, and phenomenal educators • • • •
in pediatric orthopedics Perform a variety of procedures in a safe and supportive environment Try out new techniques, and partake in rarer, more complicated operations Ask your most pertinent questions in a more-relaxed, less-formal setting Catch up with old colleagues, meet new peers and build lasting relationships for the rest of your professional life
Supporting CME programs is integral to the company’s philosophical commitment to education, says Dr. Peter F. Armstrong, the Chief Medical Officer of OrthoPediatrics:
“Hands-on, interactive training makes a major contribution toward educating a new generation of surgeons, who are taking the torch from the old.” And OrthoPediatrics’ dedication to education will continue for years to come.
OrthoPediatrics cordially invites you to join us in 2017 Stay in touch: . www.orthopediatrics.com .
1ST ANNUAL PEDIATRIC ORTHOPEDIC SURGICAL TECHNIQUES LAB
Note This document is intended exclusively for experts in the field, i.e. physicians in particular, and expressly not for laypersons. The information on the procedures contained in this document is of a general nature and does not represent medical advice or recommendations. Since this information does not constitute any diagnostic or therapeutic statement with regard to any individual medical case, individual examination and advising of the respective patient are absolutely necessary and are not replaced by this document in whole or in part. This document was commissioned by OrthoPediatrics. The contents of this document are based upon presentations given during the Pediatric Orthopedic Surgical Techniques Lab in Memphis, Tennessee, USA, on 30 September and 1 October, 2016. The statements presented within this document are the opinions of the presenters and may or may not represent the opinions of OrthoPediatrics. The information contained in this document was gathered and compiled by medical experts and OrthoPediatrics employees to the best of their knowledge. The greatest care was taken to ensure the accuracy and ease of understanding of the information used and presented. OrthoPediatrics does not assume any liability, however, for the timeliness, accuracy, completeness or quality of the information and excludes any liability for tangible or intangible losses that may be caused by the use of this information.
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