NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report | 174173 | NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report

Limb Deformity Program Tackles Rare Surgeries for Pediatric Patients with Congenital, Developmental and Acquired Deformities

ORTHOPEDICS

ORTH

OPED

ICS

Total discharges:

1,075

Total clinic visits:

36,904

Total surgical cases:

2,214

A unique, multidisciplinary team of physicians and therapists – including experts from genetics, endocrinology and rheumatology – is providing comprehensive care for children with congenital, developmental or post-trauma limb malformations through the Limb Deformity Program in the Department of Orthopedics at Nationwide Children’s Hospital.

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Pre-contoured submuscular plates for femur fractures offer excellent outcomes.

NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report | 176

A unique, multidisciplinary team of physicians

and therapists – including experts from genetics,

endocrinology and rheumatology – is providing

comprehensive care for children with congenital,

developmental or post-trauma limb malformations

through the Limb Deformity Program in the

Department of Orthopedics at Nationwide

Children’s Hospital. “The education for the families

can start even before the baby is born,”

says Daniel K. Ruggles, DO, an orthopedic

surgeon and faculty member of the Department of

Orthopedics at Nationwide Children’s. “If a baby

in utero has been diagnosed in an ultrasound with a

clubfoot or other congenital deformity, we can talk

about things so they can prepare. You do have to set

expectations, but there is no reason why you can’t

be optimistic when you set those expectations.”

The goal is to present families with a range of

available surgical and non-surgical options, many

of which have only been introduced within the last

five years. These include alternatives to amputation,

bracing, joint and limb reconstruction, plastic

surgery, prosthetics or orthotics – or a combination

of techniques designed to help the child gain

maximum functionality and confidence.

“A lot of the children who have congenital problems

here are already involved in other programs,”

explains Dr. Ruggles, who is also a clinical assistant

professor of Orthopedic Surgery at The Ohio State

University. “The nice thing about being here is that

we have every sub-specialty that children with these

congenital problems need. Every department can

stay on the same page and provide total care when

it comes to these children.”

After joining the Department of Orthopedics in

March of 2013, Dr. Ruggles became one of the

first surgeons in Ohio to use a new magnetically

controlled lengthening nail, specifically designed

for pediatric patients, to perform limb-length-

ening surgery on three children with congenital

malformations at Nationwide Children’s. This

technology may also be a treatment option for

other conditions, such as deformities caused by

neuromuscular diseases or trauma injuries.

“This is probably one of the biggest orthopedic ad-

vances I’ve seen for young children who need limb

lengthening,” says Dr. Ruggles. “Ideally, any large

pediatric hospital would have this program, but it’s

just not that common. We can offer something here

that can’t be found elsewhere.”

ORTHOPEDICS

175 | NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report

Limb Deformity Program Tackles Rare Surgeries for Pediatric Patients with Congenital, Developmental and Acquired Deformities

Dr. Daniel Ruggles

NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report | 178177 | NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report

Department, Section, and Program Reports

ORTHOPAEDICSThe Department of Orthopaedics at Nationwide Children’s Hospital provides diagnosis, evaluation, and treatment for all orthopaedic conditions and disorders in infants, children, and adolescents. Inpatient, outpatient, and emergency services are provided to patients with a wide range of developmental, congenital, neuromuscular, and posttraumatic problems of the musculoskeletal system, trauma and fractures, scoliosis, and other spinal abnormalities.

STAFF PHYSICIANS AND FACULTYKevin E. Klingele, MDChiefAdjunct Assistant Professor of Orthopaedics

FULL-TIME NCH FACULTYAllan C. Beebe, MDDirector, Orthopaedic TraumaAssistant Professor of Orthopaedics

Matthew C. Beran, MDAssistant Professor of Orthopaedics

Laura E. Gill, MD

John R. Kean, MDAssistant Professor of Orthopaedics

Jan E. Klamar, MDAssistant Professor of Orthopaedics

Daniel K. Ruggles, DOAssistant Professor of Orthopaedics

Walter P. Samora III, MDDirector, Residency ProgramAssistant Professor of Orthopaedics

OSU-AFFILIATE FACULTYHisham M. Awan, MDClinical Assistant Professor of Orthopaedic Surgery

Joel L. Mayerson, MDClinical Assistant Professor of Orthopaedic Surgery

Thomas J. Scharschmidt, MDClinical Assistant Professor of Orthopaedic Surgery

COMMUNITY-BASED FACULTYBrent A. Bickel, MD

Richard A. Fankhauser, MD

Jonathan B. Feibel, MD

Terry T. Fowler, MD

Steven T. Gaines, MD

Robert T. Gorsline, MD

Martin J. Gottesman, MDClinical Assistant Professor of Orthopaedics

David Hannallah, MD

David F. Huber, MD

Michael S. Lefkowitz, MD

James E. Popp, MDCo-Director, Hand ServiceAdjunct Assistant Professor of Orthopaedics

Daniel P. Quinn, MD

Desmond J. Stutzman, DO

Corey L. Van Hoff, MD

Marlo O. VanSteyn, MD

Raymond K. Wurapa, MD

The Department of Orthopaedic Surgery faculty participate in the education of health care professionals at several levels. Residents, medical students, and nurses from The Ohio State University, Ohio Health, and Mount Carmel Health System receive all of their pediatric orthopaedic experience at Nationwide Children’s Hospital. The Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship program rounds out the extensive educational program. Surgical and nonsurgical expertise includes:

• Clubfoot• Fractures, pediatric trauma and fracture care• Neuromuscular disorders, including cerebral

palsy and myelomeningocele• Scoliosis and spinal disorders• Musculoskeletal tumors• Pediatric hand and foot disorders• Limb length discrepancy• Bone and joint infections

• Pediatric and adolescent sports medicine• Pediatric and adolescent hip deformity

reconstruction including developmental hip dysplasia, Legg-Calve-Perthes disease

• Slipped capital femoral epiphysis• Pediatric congenital hand conditions

Research interests continue to expand within several areas of the Department of Pediatric Orthopaedics. With the appointment of Allan Beebe, MD, as director of pediatric orthopaedic trauma, research initiatives related to pediatric fracture care resulted in publications that may change the management of supracondylar humerus fractures, pediatric femur fractures, and both bone forearm fractures. A novel technique of submuscular femoral plating for length-unstable femur fractures has shown excellent outcomes. Now published, results for a large cohort of patients have shown patients to heal, walk, and return to sports quicker and without the complications seen with previous techniques. Sports medicine-directed research included publications describing improved outcomes for patients treated surgically for multifocal osteochondritis dissicans of the knee and the benefit of femoral nerve blocks for outpatient knee arthroscopy. Collaborative efforts with the departments of anesthesiology and interventional radiology resulted in several publications highlighting intraoperative care of complex spinal fusion patients and percutaneous treatment of aneurysmal bone cysts, respectively.

Numerous presentations were made within local, regional, national, and international settings, including a talk entitled “Treatment of acute, unstable Slipped Capital Femoral Epiphysis (SCFE) via the modified Dunn procedure.” This presentation highlighted the largest group to date treated by a single surgeon with such procedure. Outcomes revealed a 6.9 percent avascular necrosis (AVN) rate and normalization of radiographic hip parameters.

In November 2014, the department teamed with the Division of Sports Medicine to hold its second annual Sports Medicine and Orthopaedics Conference at Nationwide Children’s Hospital. Over 200 participants, including pediatricians, physical therapists, athletic trainers, and general orthopaedists from Ohio and nearby states attended this full-day conference that offered sessions on a wide variety of sports and orthopaedic topics.

Educational initiatives continue to grow as our ACGME-accredited program now trains approximately 50 rotating residents and fellows per academic year. The educational program includes a daily trauma conference, a weekly reading and X-ray conference, a pre-op indications conference, a surgical milestones conference, morbidity and mortality, current literature, research meetings, and a monthly fellow’s conference. Pediatric orthopaedic grand rounds and a pediatric-specific lecture series is conducted on a monthly basis, 10 months per year. The Ohio State University Orthopaedic Surgery residents elected Residency Program Director Walter Samora, MD, “Educator of the Year.” He continues to strive to develop a rich academic environment for all residents, fellows, and students that rotate through our program. They have an opportunity to participate in specialty clinics such as hand, tumor, spine, trauma, cerebral palsy, myelomeningocele, and limb deformity. Three free-standing clinic locations allow for a diverse population of patients.

The department continues to show growth in clinical and surgical volumes, academic productivity, and surgical innovation within several areas. In pursuit of innovative treatment for all patients, the expertise of Dan Ruggles, DO, has brought new surgical techniques for the management of congenital limb deformity, leg length discrepancy, and complex trauma conditions. Additionally, he was part of the teaching faculty at the Baltimore Limb Deformity Conference held in September 2013. Matthew Beran, MD, has expanded the treatment of pediatric and adolescent athletes with newer techniques in anatomic anterior cruciate ligament (ACL) reconstruction, and elbow and shoulder arthroscopy.

179 | NATIONWIDE CHILDREN’S HOSPITAL | 2013-14 Annual Report

PUBLICATIONSBackes JR, Durbin TC, Bentley JC, Klingele KE. “Multifocal juvenile osteochondritis dissecans of the knee: a case series.” Journal of Pediatric Orthopedics. Vol. 34, No.4 (2014): 453 – 8.

Beals C, Rogers A, Wakley P, Mayerson JL, Scharschmidt TJ. “Hibernomas: a single institution experience and review of literature.” Medical Oncology. Vol. 31, No.1 (2014): 769.

Bowden SA, Beebe AC, Wildman S. “Late onset hypophosphatemic rickets in a 13-year-old boy presenting with knee pain and valgus deformity caused by a novel mosaic PHEX gene mutation.” Bone Abstracts. Vol. 2, (2013): 106.

Bowden SA, Patel H, Beebe AC, McBride K. “Improvement in valgus deformity in hypophosphatemic rickets due to primary de Toni-Debré-Fanconi syndrome treated with phosphate, calcitriol and alkali therapy.” Bone Abstracts. Vol. 2, (2013): 26 – 7.

Bowden SA, Patel HP, Beebe A, McBride KL. “Successful medical therapy for hypophosphatemic rickets due to mitochondrial Complex I deficiency induced de Toni-Debré-Fanconi syndrome.” Case Reports in Pediatrics. [Epub 2013 Dec 10]. doi: 10.1155/2013/354314.

Dodwad SN, Savage J, Scharschmidt TJ, Patel A. “Evaluation and treatment of spinal metastatic disease.” Cancer Treatment and Research. Vol. 162, (2014): 131 – 50.

Gaski G, Hansen D, Willis L, Bos G, Kean JR. “Intramedullary rod fixation of fibrous dysplasia without use of bisphosphonates.” Journal of Children’s Orthopaedics. Vol. 7, No.4 (2013): 277 – 83.

Horn P, Badowski E, Klingele K. “Orthopaedic clinical care model in a pediatric orthopaedic setting: outcomes of a 1:1 model-orthopaedic surgeon and nurse practitioner.” Journal of Orthopedic Nursing. Vol. 33, No.3 (2014): 142 – 6.

Joehlin-Price AS, Huang JH, Brooks JS, Scharschmidt TJ, Iwenofu OH. “PAX-8 expression in cutaneous ciliated cysts: evidence for Müllerian origin.” American Journal of Dermatopathology. Vol. 36, No.2 (2014): 167 – 70.

Karnes JM, Mayerson JL, Scharschmidt TJ. “Is orthopaedics more competitive today than when my attending matched? An analysis of National Resident Matching Program data for orthopaedic PGY1 applicants from 1984 to 2011.” Journal of Surgical Education. Vol. 71, No.4 (2014): 530 – 42.

Kurt H, Mayerson JL, Iwenofu OH. “An unusual presentation of a small-size synovial sarcoma with indolent course of over 30-years: a cautionary tale!” Applied Immunohistochemistry Molecular Morphology. Vol. 21, No.5 (2013): 478 – 9.

Lucas D, Willis L, Klingele KE. “Factors predictive of early radiographic failure following closed reduction of Gartland Type II supracondylar humeral fractures.” Journal of Orthopedic Trauma. Vol. 27, No.3 (2013): 457 – 61.

Manring MM, Panzo J, Mayerson JL. “A framework for improving resident research participation and scholarly output.” Journal of Surgical Education. Vol. 71, No.1 (2014): 8 – 13.

Mayerson JL, Wooldridge AN, Scharschmidt TJ. “Pelvic resection: Current concepts.” Journal American Academy of Orthopedic Surgeons. Vol. 22, No.4 (2014): 214 – 22.

Mendel E, Nathoo N, Scharschmidt TJ, Schmidt C, Boehmler J, Mayerson JL. “Creation of false pedicles and a neo-pelvis for lumbopelvic reconstruction following en bloc resection of an iliosacral chondrosarcoma with lumbar spine extension.” Journal of Neurosurgery. Spine. Vol. 20, No.3 (2014): 327 – 34.

Ng VY, Kean JR, Glassman AH. “Limb-length discrepancy after hip arthroplasty.” Journal of Bone and Joint Surgery American. Vol. 95, No.15 (2013): 1426 – 36.

Orvets ND, Mayerson JL, Wakely PE. “Extranodal Rosai-Dorfman disease as solitary lesion of the tibia in a 56-year-old female.” American Journal of Orthopedics. Vol. 42, No.9 (2013): 420 – 22.

Samora WP, Guerriero M, Willis L, Klingele KE. “Submuscular bridge plating for length unstable, pediatric femur fractures.” Journal of Pediatric Orthopedics. Vol. 33, No.8 (2013): 797 – 802.

Samora JB, Klingele KE. “Septic arthritis of the hip in the neonate: acute treatment and late reconstruction.” Journal of American Academy of Orthopedic Surgeons. Vol. 21, No.10 (2013): 632 – 41.

Samora JB, Klingele KE, Beebe AC, Kean JR, Klamar J, Beran MC, Willis LM, Yin H, Samora WP. “Is there still a place for cast wedging in pediatric forearm fractures?” Journal of Pediatric Orthopedics. Vol. 34, No.3 (2014): 246 – 52.

Shiels WE II, Mayerson JL. “Percutaneous doxycycline treatment of aneurysmal bone cysts with low recurrence rate: a preliminary report.” Clinical Orthopaedics Related Research. Vol. 471, No.8 (2013): 2675 – 83.

Talarczyk MR, Boehmler JH, Ljungquist K, Tiwari P, Mayerson JL, Miller M. “External hemipelvectomy pelvic ring stabilization: the unique application of chimeric lower extremity pedicled fillet flaps.” Journal of Reconstructive Microsurgery. Vol. 29, No.6 (2013): 367 – 72.

von Mehren M, Randall RL, Benjamin RS, Boles S, Bui MM, Casper ES, Conrad EU III, DeLaney TF, Ganjoo KN, George S, Gonzalez RJ, Heslin MJ, Kane JM III, Mayerson J, McGarry SV, Meyer C, O’Donnell RJ, Pappo AS, Paz IB, Pfeifer JD, Riedel RF, Schuetze S, Schupak KD, Schwartz HS, Van Tine BA, Wayne JD, Bergman MA, Sundar H. “Gastrointestinal stromal tumors.” National Comprehensive Cancer Network. Version 2.2014. Vol. 12, No.6: 853 – 62.

von Mehren M, Randall RL, Benjamin RS, Boles S, Bui MM, Casper ES, Conrad EU III, Delaney TF, Ganjoo KN, George S, Gonzalez RJ, Heslin MJ, Kane JM III, Mayerson J, McGarry SV, Meyer C, O’Donnell RJ, Pappo AS, Paz IB, Pfeifer JD, Riedel RF, Schuetze S, Schupak KD, Schwartz HS, Van Tine BA, Wayne JD, Bergman MA, Sundar H. “Soft tissue sarcoma.” National Comprehensive Cancer Network. Version 2.2014. Vol. 12, No.4: 473 – 83.

FAST FACTS

July 2013 – June 2014

Inpatient Discharges: 577Observation and Outpatient-in-a-Bed Discharges: 498Total Discharges: 1,075Average Length of Stay*: 2.9Average Daily Census*: 4.5Patient Days*: 1,654Total Surgical Cases: 2,214Inpatient Consults: 1,599Dublin Orthopaedic Clinic Visits: 7,584East Broad Orthopaedic Clinic Visits: 418Orthopaedic Clinic Visits: 16,645Orthopaedic Oncology Clinic Visits: 112Westerville Orthopaedic Clinic Visits: 12,145Total Orthopaedic Clinic Visits: 36,904*Excludes observation and outpatient-in-a-bed patients.