Wade Shrader - Academia.edu (original) (raw)
Papers by Wade Shrader
Journal of Children's Orthopaedics
Purpose: The purpose of this study was to develop consensus for the surgical indications of anter... more Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%–79% falling into the highest or lowest 2 ratings. Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and ...
Journal of the Pediatric Orthopaedic Society of North America
Management of the ambulatory patient with cerebral palsy is complicated as each child has differe... more Management of the ambulatory patient with cerebral palsy is complicated as each child has differences in the degree and extent of motor involvement; neurologic features (dystonia, ataxia) as well as other physical and social co-morbidities. No where else in pediatric orthopaedics is the care of these children/adolescents equally dependent on assessment tools and methods, treatment strategies, experience and the need for excellent support from our partners in rehabilitation medicine, occupational and physical therapy and orthotics. In this edition we begin a year-long study in this topic.
Journal of the Pediatric Orthopaedic Society of North America
Population based studies have found that approximately 33% of children with cerebral palsy are at... more Population based studies have found that approximately 33% of children with cerebral palsy are at risk for progressive lateral hip displacement/subluxation during childhood. There is growing evidence supporting the practice of hip surveillance for children with cerebral palsy and many developed countries have established national and state surveillance programs. However, across POSNA there is a lack of consensus regarding a radiographic hip screening protocol for children with cerebral palsy. Therefore, the purpose of this quality initiative was to develop a POSNA-wide radiographic hip screening schedule using a Modified Delphi technique. A group of 24 pediatric orthopedic surgeons participated in the Modified Delphi technique to achieve consensus regarding a hip radiographic screening protocol. The development of a POSNA - wide radiographic hip screening protocol has the potential to standardize screening practices across our society, decrease practice variation and ultimately impr...
Journal of the Pediatric Orthopaedic Society of North America
In this edition, we conclude our year long series on gait analysis in cerebral palsy. This compr... more In this edition, we conclude our year long series on gait analysis in cerebral palsy. This comprehensive discussion has included a focus on observational gait analysis, the methods of quantitative gait analysis, and its application for clinical decision-making. This edition focuses on severe crouch gait, a common pathology in CP with increased knee flexion, progressive knee flexion contractures, and increased energy demands with increased patellar-femoral moments that can cause early degenerative changes. Another group of outstanding experts in CP discuss the surgical treatment of this common pathology.
Journal of the Pediatric Orthopaedic Society of North America
A detailed, thoughtful examination of a patient’s gait is an important aspect of the care of most... more A detailed, thoughtful examination of a patient’s gait is an important aspect of the care of most patients in orthopaedics. Many times, an appropriate visual inspection of gait can reveal the most important pathologies seen in a general pediatric orthopaedic practice. However, some conditions, such as cerebral palsy (CP), often present with significant gait complexities and multiple impairments that negatively affect patient mobility. The use of advanced instrumented gait and motion analysis has become an essential piece of high-quality care of children with CP. In this edition, we discuss evaluation and management of transverse plane deviations. In this series, a group of gait experts will be presenting principles and tips to help us all improve in the evaluation of gait in patients with CP. This case will include clinical information, physical examination data, pertinent radiographs, links to gait videos, and motion analysis data.
Journal of the Pediatric Orthopaedic Society of North America
Analysis of a child’s gait is an important aspect of a pediatric orthopedic evaluation. Childre... more Analysis of a child’s gait is an important aspect of a pediatric orthopedic evaluation. Children with cerebral palsy often have significant gait impairments that negatively impact their ambulation, activity in society, and their quality of life. Instrumented gait analysis, with motion capture, can provide significant data to help the surgeon better understand specific pathophysiology and to plan surgical correction. Modern instrumented gait analysis is comprised of many components, including kinematics, kinetics, electromyography, pedobarography, and metabolic assessment. Newer technology allows for wearable measurement devices in the community to provide information about environmental activity, such as step counts, that augment information traditionally measured in gait laboratories. The synthesis of data from these components allow for the team to accurately assess individual components of pathological gait and systematically plan surgical procedures to address the signific...
Journal of the Pediatric Orthopaedic Society of North America, Apr 25, 2021
Abstracts of the 26th Annual Meeting of the GCMAS, 2021
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Abstracts of the 26th Annual Meeting of the GCMAS, 2021
The Journal of Bone & Joint Surgery, 2004
Constrained acetabular components have been used to treat hips with recurrent instability followi... more Constrained acetabular components have been used to treat hips with recurrent instability following total hip arthroplasty and hips that demonstrate instability during revision surgery. In such hips, when a secure cementless acetabular shell is present, the surgeon can cement a constrained liner into the existing shell. The purpose of this study was to evaluate the clinical and radiographic outcome of this technique with use of a tripolar constrained liner that was cemented into a well-fixed cementless acetabular shell. Between 1988 and 2000, constrained liners were cemented into thirty-one well-fixed cementless acetabular shells at three centers. The average age of the patients at the time of the index surgery was 72.1 years, and the indications for the procedure were recurrent hip instability in sixteen hips and intraoperative instability in fifteen hips. The patients were evaluated with respect to the clinical outcome and radiographic evidence of shell loosening and osteolysis. At an average duration of follow-up of 3.9 years, twenty-nine liners (94%) were securely fixed in the cementless shells and two constrained liners had failed. One liner failed because it separated from the cement, and one failed because of fracture of the capturing mechanism. Both hips were successfully revised with another cemented tripolar constrained liner. No acetabular component demonstrated radiographic evidence of progressive loosening or osteolysis. A constrained tripolar liner cemented into a secure, well-positioned cementless acetabular shell provides stability and durability at short-term follow-up. Careful attention to the preparation of the liner, the sizing of the component, and the cementing technique are likely to reduce the failure of this construct, which can be used for difficult cases of total hip instability.
The Journal of Bone and Joint Surgery-American Volume, 2003
Recurrent dislocation after total hip arthroplasty is a disabling complication that can be diffic... more Recurrent dislocation after total hip arthroplasty is a disabling complication that can be difficult to treat and may not be amenable to nonoperative management. The purpose of the present study was to evaluate the clinical and radiographic outcome associated with the use of a constrained acetabular component as a salvage treatment for instability after hip arthroplasty. We retrospectively reviewed the clinical and radiographic outcome of 110 arthroplasties, in 109 patients, that had been performed with use of a single design of constrained acetabular component. In seventy-nine hips the constrained component was implanted for the treatment of recurrent instability, and in thirty-one hips it was implanted because of absent or grossly deficient soft-tissue attachments that were believed to be associated with a high risk for subsequent instability. The constrained acetabular device eliminated or prevented hip instability in all patients except two, who continued to have sensations of subluxation. The mean Harris hip score improved significantly, from 62.7 points preoperatively to 76.4 points at the time of the latest follow-up (p < 0.0001). There were no instances of dislocation or disassembly of the hip components. Radiographic analysis revealed radiolucent lines around the cup in fifteen hips (14%). There was a total of nine revisions: six for deep infection, two for acetabular component loosening, and one for a periprosthetic fracture of the femur. A constrained acetabular component reliably restores and maintains hip stability in patients with recalcitrant recurrent instability and can dependably prevent dislocation in those who are at high risk because of absent or deficient soft tissues about the hip. However, because of the early appearance of radiolucent lines around some components and concerns about long-term fixation, the use of these devices should be reserved for situations in which other methods are inadequate or have already failed.
Purpose: Appropriate pain control after orthopedic surgery for children with cerebral palsy is ch... more Purpose: Appropriate pain control after orthopedic surgery for children with cerebral palsy is challenging. Inherent communication and cognitive deficits, and subsequent lack of verbal skills that are common in many of these patients make it difficult for caregivers to adequately assess pain. The appropriate assessment of pain is crucial, because under treatment of pain leads to undue suffering, patient and family anxiety, and prolonged hospital stay. However, overtreatment can lead to over sedation, respiratory depression, and unexpected ICU admission. The purpose of this study is to investigate the assessment of postoperative pain in children with cerebral palsy undergoing orthopedic surgery and comparing that to normal controls. Specifically, the study will address how complete and how accurately the nursing staff documents pain scores in children with CP compared to normal controls. Methods: This is a retrospective chart review of all children with cerebral palsy over a ten year...
American journal of orthopedics (Belle Mead, N.J.), 2009
Pathologic fractures in children occur in a variety of malignant and benign pathologic processes.... more Pathologic fractures in children occur in a variety of malignant and benign pathologic processes. Pediatric pathologic femoral neck fractures are particularly rare. Until now, all reported cases have been isolated cases, small series, or cases reported in series of adult pathologic hip fractures. The present article is the first report of a relatively large series of pathologic femoral neck fractures in a pediatric population. We identified pathologic femoral neck fractures, including 2 basicervical fractures, in 15 children (9 boys, 6 girls) ranging in age from 18 months to 15 years (mean age, 9 years) and treated between 1960 and 2000. The pathologic diagnoses were fibrous dysplasia (5 children), unicameral bone cyst (2), Ewing's sarcoma (2), osteomyelitis (2), leukemia (1), rhabdomyosarcoma (1), osteogenesis imperfecta (1), and osteopetrosis (1). Treatment methods, including time to reduction and fixation, were reviewed in detail. One patient was lost to follow-up. All others...
Acta orthopaedica Belgica, 2011
We report on two patients who sustained Salter-Harris II fractures of the distal femur with physe... more We report on two patients who sustained Salter-Harris II fractures of the distal femur with physeal widening after being tackled in football games. Preoperative MRI indicated entrapped periosteum at the physeal fracture site for both patients. Both patients underwent open reduction of the physeal fracture with removal of the entrapped periosteum and achieving an anatomic reduction. Follow-up MRI's revealed premature physeal arrest. Subsequent procedures were performed to address sequelae of premature physeal arrest. The presence of physeal widening and entrapped periosteum may reflect high-energy trauma to the physis. This can result in injury to both the epiphyseal blood supply and to the physeal cartilage (germinal zone) resulting in physeal arrest despite anatomic reduction after removal of the entrapped periosteum. Upon literature review, pre-operative MRI demonstrating entrapped periosteum has not been previously reported. We hypothesize that the presence of entrapped perio...
Orthopedics, 2009
There is little data evaluating the risk factors, demographics, and prognoses for nonunions in ch... more There is little data evaluating the risk factors, demographics, and prognoses for nonunions in children. Previous literature has reviewed time periods when contemporary techniques of internal fixation and management of open injuries had not been available. The purpose of this retrospective study was to evaluate a large consecutive series of pediatric nonunions treated at a level I trauma center. Between 1985 and 2000, 43 nonunions in 42 pediatric patients with a mean age of 9 years and 9 months (range, 3-14 years) were identified at our level I trauma center. Eleven of the original 43 fractures were open and 5 presented with active infection. Patients were observed until union or a minimum of 1 year with a mean follow-up of 50 months. Twenty of 43 nonunions (47%) were located around the elbow. Seventeen of 43 nonunions (39%) were diaphyseal. The operative fractures required a mean of 3.6 surgeries (range, 1-19 surgeries) to achieve bony union. All secondary attempts to achieve union were successful at last follow-up. Although nonunions in the pediatric population are rare, these data underscore the importance of careful evaluation and treatment of these fractures at risk for nonunion.
Journal of Pediatric Orthopaedics, 2015
Background: Patient satisfaction survey scores are increasingly being tied to incentive compensat... more Background: Patient satisfaction survey scores are increasingly being tied to incentive compensation, impact how we practice medicine, influence decisions on where patients seek care, and in the future may be required for accreditation. The goal of this study is to compare the results of an internal distribution of patient satisfaction surveys at the point of care to responses received by mail in a hospital-based, high-volume pediatric orthopaedic practice. Methods: A pediatric outpatient survey is used at our institution to evaluate patient satisfaction. Surveys are randomly mailed out to families seen in our clinic by the survey vendor, and the results are determined on a quarterly basis. We distributed the same survey in a similar manner in our clinic. The results of the surveys, external/mailed (EXM) versus internal/point of care (INP) over the same 3-month time period (second quarter 2013) were compared. The survey questions are dichotomized from an ordinal scale into either excellent (9 to 10) or not excellent (0 to 8) commonly used in patient satisfaction methodology. We evaluated the raw data from the INP surveys for the question on provider rating by evaluating the mean score, the standard excellent response (9 to 10), and an expanded excellent response (8 to 10). Results: Response rate was 72/469 (15.4%) for EXM, and 231/ 333 (69.4%) for INP. An excellent response for the "rating your provider" question was 72.2% (EXM) versus 84.8% (INP) (P = 0.015). Our analysis of the raw data (INP) has a mean rating of 9.42. The expanded scale (8 to 10) for an excellent response increased the provider rating to 94.4% (P = 0.001). Waiting time response within 15 minutes was the only item that correlated with rating of provider (P = 0.02). For the majority of the items, the INP responses were consistently higher than the EXM responses, including 6/7 responses that were statistically significant (P < 0.05). Conclusions: As mandated by the Centers for Medicare and Medicaid Services, patient satisfaction surveys will be important in determining health care outcomes. Properly designed and administered surveys provide robust measures of quality. Our study reinforces methodological concerns about patient satisfaction surveys distributed in a high-volume pediatric subspecialty practice. Further research is needed to evaluate the patients' health care experience and true quality of care in pediatric subspecialty ambulatory settings.
Orthopedics, 2008
Elbow fractures in children can be difficult diagnoses for inexperienced physicians to make. The ... more Elbow fractures in children can be difficult diagnoses for inexperienced physicians to make. The purpose of this prospective study was to determine the accuracy of radiograph interpretation of elbow fractures in children by emergency room (ER) physicians. Thirty fractures were analyzed. The ER physician&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s radiograph interpretation was compared to the final interpretation by the treating staff pediatric orthopedic surgeon. Accuracy rates were determined for overall agreement and by fracture subtype. Overall accuracy of ER physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; interpretation was 53% (16/30). This study underscores the importance of educating ER physicians and residents in children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s fracture interpretation to optimize patient outcomes. Orthopedists need to be vigilant when taking care of these patients to prevent unnecessary complications.
Orthopedic Clinics of North America, 2008
Basic radiography and ossification of the pediatric elbow Radiographs of pediatric elbow fracture... more Basic radiography and ossification of the pediatric elbow Radiographs of pediatric elbow fractures are difficult to interpret because most of the child's
Journal of Shoulder and Elbow Surgery, 2005
Proximal humerus fractures are difficult to define because of their extreme variability and poten... more Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures-not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.
Journal of Pediatric Orthopaedics, 2014
Journal of Children's Orthopaedics
Purpose: The purpose of this study was to develop consensus for the surgical indications of anter... more Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%–79% falling into the highest or lowest 2 ratings. Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and ...
Journal of the Pediatric Orthopaedic Society of North America
Management of the ambulatory patient with cerebral palsy is complicated as each child has differe... more Management of the ambulatory patient with cerebral palsy is complicated as each child has differences in the degree and extent of motor involvement; neurologic features (dystonia, ataxia) as well as other physical and social co-morbidities. No where else in pediatric orthopaedics is the care of these children/adolescents equally dependent on assessment tools and methods, treatment strategies, experience and the need for excellent support from our partners in rehabilitation medicine, occupational and physical therapy and orthotics. In this edition we begin a year-long study in this topic.
Journal of the Pediatric Orthopaedic Society of North America
Population based studies have found that approximately 33% of children with cerebral palsy are at... more Population based studies have found that approximately 33% of children with cerebral palsy are at risk for progressive lateral hip displacement/subluxation during childhood. There is growing evidence supporting the practice of hip surveillance for children with cerebral palsy and many developed countries have established national and state surveillance programs. However, across POSNA there is a lack of consensus regarding a radiographic hip screening protocol for children with cerebral palsy. Therefore, the purpose of this quality initiative was to develop a POSNA-wide radiographic hip screening schedule using a Modified Delphi technique. A group of 24 pediatric orthopedic surgeons participated in the Modified Delphi technique to achieve consensus regarding a hip radiographic screening protocol. The development of a POSNA - wide radiographic hip screening protocol has the potential to standardize screening practices across our society, decrease practice variation and ultimately impr...
Journal of the Pediatric Orthopaedic Society of North America
In this edition, we conclude our year long series on gait analysis in cerebral palsy. This compr... more In this edition, we conclude our year long series on gait analysis in cerebral palsy. This comprehensive discussion has included a focus on observational gait analysis, the methods of quantitative gait analysis, and its application for clinical decision-making. This edition focuses on severe crouch gait, a common pathology in CP with increased knee flexion, progressive knee flexion contractures, and increased energy demands with increased patellar-femoral moments that can cause early degenerative changes. Another group of outstanding experts in CP discuss the surgical treatment of this common pathology.
Journal of the Pediatric Orthopaedic Society of North America
A detailed, thoughtful examination of a patient’s gait is an important aspect of the care of most... more A detailed, thoughtful examination of a patient’s gait is an important aspect of the care of most patients in orthopaedics. Many times, an appropriate visual inspection of gait can reveal the most important pathologies seen in a general pediatric orthopaedic practice. However, some conditions, such as cerebral palsy (CP), often present with significant gait complexities and multiple impairments that negatively affect patient mobility. The use of advanced instrumented gait and motion analysis has become an essential piece of high-quality care of children with CP. In this edition, we discuss evaluation and management of transverse plane deviations. In this series, a group of gait experts will be presenting principles and tips to help us all improve in the evaluation of gait in patients with CP. This case will include clinical information, physical examination data, pertinent radiographs, links to gait videos, and motion analysis data.
Journal of the Pediatric Orthopaedic Society of North America
Analysis of a child’s gait is an important aspect of a pediatric orthopedic evaluation. Childre... more Analysis of a child’s gait is an important aspect of a pediatric orthopedic evaluation. Children with cerebral palsy often have significant gait impairments that negatively impact their ambulation, activity in society, and their quality of life. Instrumented gait analysis, with motion capture, can provide significant data to help the surgeon better understand specific pathophysiology and to plan surgical correction. Modern instrumented gait analysis is comprised of many components, including kinematics, kinetics, electromyography, pedobarography, and metabolic assessment. Newer technology allows for wearable measurement devices in the community to provide information about environmental activity, such as step counts, that augment information traditionally measured in gait laboratories. The synthesis of data from these components allow for the team to accurately assess individual components of pathological gait and systematically plan surgical procedures to address the signific...
Journal of the Pediatric Orthopaedic Society of North America, Apr 25, 2021
Abstracts of the 26th Annual Meeting of the GCMAS, 2021
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Abstracts of the 26th Annual Meeting of the GCMAS, 2021
The Journal of Bone & Joint Surgery, 2004
Constrained acetabular components have been used to treat hips with recurrent instability followi... more Constrained acetabular components have been used to treat hips with recurrent instability following total hip arthroplasty and hips that demonstrate instability during revision surgery. In such hips, when a secure cementless acetabular shell is present, the surgeon can cement a constrained liner into the existing shell. The purpose of this study was to evaluate the clinical and radiographic outcome of this technique with use of a tripolar constrained liner that was cemented into a well-fixed cementless acetabular shell. Between 1988 and 2000, constrained liners were cemented into thirty-one well-fixed cementless acetabular shells at three centers. The average age of the patients at the time of the index surgery was 72.1 years, and the indications for the procedure were recurrent hip instability in sixteen hips and intraoperative instability in fifteen hips. The patients were evaluated with respect to the clinical outcome and radiographic evidence of shell loosening and osteolysis. At an average duration of follow-up of 3.9 years, twenty-nine liners (94%) were securely fixed in the cementless shells and two constrained liners had failed. One liner failed because it separated from the cement, and one failed because of fracture of the capturing mechanism. Both hips were successfully revised with another cemented tripolar constrained liner. No acetabular component demonstrated radiographic evidence of progressive loosening or osteolysis. A constrained tripolar liner cemented into a secure, well-positioned cementless acetabular shell provides stability and durability at short-term follow-up. Careful attention to the preparation of the liner, the sizing of the component, and the cementing technique are likely to reduce the failure of this construct, which can be used for difficult cases of total hip instability.
The Journal of Bone and Joint Surgery-American Volume, 2003
Recurrent dislocation after total hip arthroplasty is a disabling complication that can be diffic... more Recurrent dislocation after total hip arthroplasty is a disabling complication that can be difficult to treat and may not be amenable to nonoperative management. The purpose of the present study was to evaluate the clinical and radiographic outcome associated with the use of a constrained acetabular component as a salvage treatment for instability after hip arthroplasty. We retrospectively reviewed the clinical and radiographic outcome of 110 arthroplasties, in 109 patients, that had been performed with use of a single design of constrained acetabular component. In seventy-nine hips the constrained component was implanted for the treatment of recurrent instability, and in thirty-one hips it was implanted because of absent or grossly deficient soft-tissue attachments that were believed to be associated with a high risk for subsequent instability. The constrained acetabular device eliminated or prevented hip instability in all patients except two, who continued to have sensations of subluxation. The mean Harris hip score improved significantly, from 62.7 points preoperatively to 76.4 points at the time of the latest follow-up (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). There were no instances of dislocation or disassembly of the hip components. Radiographic analysis revealed radiolucent lines around the cup in fifteen hips (14%). There was a total of nine revisions: six for deep infection, two for acetabular component loosening, and one for a periprosthetic fracture of the femur. A constrained acetabular component reliably restores and maintains hip stability in patients with recalcitrant recurrent instability and can dependably prevent dislocation in those who are at high risk because of absent or deficient soft tissues about the hip. However, because of the early appearance of radiolucent lines around some components and concerns about long-term fixation, the use of these devices should be reserved for situations in which other methods are inadequate or have already failed.
Purpose: Appropriate pain control after orthopedic surgery for children with cerebral palsy is ch... more Purpose: Appropriate pain control after orthopedic surgery for children with cerebral palsy is challenging. Inherent communication and cognitive deficits, and subsequent lack of verbal skills that are common in many of these patients make it difficult for caregivers to adequately assess pain. The appropriate assessment of pain is crucial, because under treatment of pain leads to undue suffering, patient and family anxiety, and prolonged hospital stay. However, overtreatment can lead to over sedation, respiratory depression, and unexpected ICU admission. The purpose of this study is to investigate the assessment of postoperative pain in children with cerebral palsy undergoing orthopedic surgery and comparing that to normal controls. Specifically, the study will address how complete and how accurately the nursing staff documents pain scores in children with CP compared to normal controls. Methods: This is a retrospective chart review of all children with cerebral palsy over a ten year...
American journal of orthopedics (Belle Mead, N.J.), 2009
Pathologic fractures in children occur in a variety of malignant and benign pathologic processes.... more Pathologic fractures in children occur in a variety of malignant and benign pathologic processes. Pediatric pathologic femoral neck fractures are particularly rare. Until now, all reported cases have been isolated cases, small series, or cases reported in series of adult pathologic hip fractures. The present article is the first report of a relatively large series of pathologic femoral neck fractures in a pediatric population. We identified pathologic femoral neck fractures, including 2 basicervical fractures, in 15 children (9 boys, 6 girls) ranging in age from 18 months to 15 years (mean age, 9 years) and treated between 1960 and 2000. The pathologic diagnoses were fibrous dysplasia (5 children), unicameral bone cyst (2), Ewing's sarcoma (2), osteomyelitis (2), leukemia (1), rhabdomyosarcoma (1), osteogenesis imperfecta (1), and osteopetrosis (1). Treatment methods, including time to reduction and fixation, were reviewed in detail. One patient was lost to follow-up. All others...
Acta orthopaedica Belgica, 2011
We report on two patients who sustained Salter-Harris II fractures of the distal femur with physe... more We report on two patients who sustained Salter-Harris II fractures of the distal femur with physeal widening after being tackled in football games. Preoperative MRI indicated entrapped periosteum at the physeal fracture site for both patients. Both patients underwent open reduction of the physeal fracture with removal of the entrapped periosteum and achieving an anatomic reduction. Follow-up MRI's revealed premature physeal arrest. Subsequent procedures were performed to address sequelae of premature physeal arrest. The presence of physeal widening and entrapped periosteum may reflect high-energy trauma to the physis. This can result in injury to both the epiphyseal blood supply and to the physeal cartilage (germinal zone) resulting in physeal arrest despite anatomic reduction after removal of the entrapped periosteum. Upon literature review, pre-operative MRI demonstrating entrapped periosteum has not been previously reported. We hypothesize that the presence of entrapped perio...
Orthopedics, 2009
There is little data evaluating the risk factors, demographics, and prognoses for nonunions in ch... more There is little data evaluating the risk factors, demographics, and prognoses for nonunions in children. Previous literature has reviewed time periods when contemporary techniques of internal fixation and management of open injuries had not been available. The purpose of this retrospective study was to evaluate a large consecutive series of pediatric nonunions treated at a level I trauma center. Between 1985 and 2000, 43 nonunions in 42 pediatric patients with a mean age of 9 years and 9 months (range, 3-14 years) were identified at our level I trauma center. Eleven of the original 43 fractures were open and 5 presented with active infection. Patients were observed until union or a minimum of 1 year with a mean follow-up of 50 months. Twenty of 43 nonunions (47%) were located around the elbow. Seventeen of 43 nonunions (39%) were diaphyseal. The operative fractures required a mean of 3.6 surgeries (range, 1-19 surgeries) to achieve bony union. All secondary attempts to achieve union were successful at last follow-up. Although nonunions in the pediatric population are rare, these data underscore the importance of careful evaluation and treatment of these fractures at risk for nonunion.
Journal of Pediatric Orthopaedics, 2015
Background: Patient satisfaction survey scores are increasingly being tied to incentive compensat... more Background: Patient satisfaction survey scores are increasingly being tied to incentive compensation, impact how we practice medicine, influence decisions on where patients seek care, and in the future may be required for accreditation. The goal of this study is to compare the results of an internal distribution of patient satisfaction surveys at the point of care to responses received by mail in a hospital-based, high-volume pediatric orthopaedic practice. Methods: A pediatric outpatient survey is used at our institution to evaluate patient satisfaction. Surveys are randomly mailed out to families seen in our clinic by the survey vendor, and the results are determined on a quarterly basis. We distributed the same survey in a similar manner in our clinic. The results of the surveys, external/mailed (EXM) versus internal/point of care (INP) over the same 3-month time period (second quarter 2013) were compared. The survey questions are dichotomized from an ordinal scale into either excellent (9 to 10) or not excellent (0 to 8) commonly used in patient satisfaction methodology. We evaluated the raw data from the INP surveys for the question on provider rating by evaluating the mean score, the standard excellent response (9 to 10), and an expanded excellent response (8 to 10). Results: Response rate was 72/469 (15.4%) for EXM, and 231/ 333 (69.4%) for INP. An excellent response for the "rating your provider" question was 72.2% (EXM) versus 84.8% (INP) (P = 0.015). Our analysis of the raw data (INP) has a mean rating of 9.42. The expanded scale (8 to 10) for an excellent response increased the provider rating to 94.4% (P = 0.001). Waiting time response within 15 minutes was the only item that correlated with rating of provider (P = 0.02). For the majority of the items, the INP responses were consistently higher than the EXM responses, including 6/7 responses that were statistically significant (P < 0.05). Conclusions: As mandated by the Centers for Medicare and Medicaid Services, patient satisfaction surveys will be important in determining health care outcomes. Properly designed and administered surveys provide robust measures of quality. Our study reinforces methodological concerns about patient satisfaction surveys distributed in a high-volume pediatric subspecialty practice. Further research is needed to evaluate the patients' health care experience and true quality of care in pediatric subspecialty ambulatory settings.
Orthopedics, 2008
Elbow fractures in children can be difficult diagnoses for inexperienced physicians to make. The ... more Elbow fractures in children can be difficult diagnoses for inexperienced physicians to make. The purpose of this prospective study was to determine the accuracy of radiograph interpretation of elbow fractures in children by emergency room (ER) physicians. Thirty fractures were analyzed. The ER physician&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s radiograph interpretation was compared to the final interpretation by the treating staff pediatric orthopedic surgeon. Accuracy rates were determined for overall agreement and by fracture subtype. Overall accuracy of ER physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; interpretation was 53% (16/30). This study underscores the importance of educating ER physicians and residents in children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s fracture interpretation to optimize patient outcomes. Orthopedists need to be vigilant when taking care of these patients to prevent unnecessary complications.
Orthopedic Clinics of North America, 2008
Basic radiography and ossification of the pediatric elbow Radiographs of pediatric elbow fracture... more Basic radiography and ossification of the pediatric elbow Radiographs of pediatric elbow fractures are difficult to interpret because most of the child's
Journal of Shoulder and Elbow Surgery, 2005
Proximal humerus fractures are difficult to define because of their extreme variability and poten... more Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures-not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.
Journal of Pediatric Orthopaedics, 2014