THE CHILDREN'S HOSPITAL
James R. Kasser, MD
JOHN E. HALL PROFESSOR OF ORTHOPAEDIC SURGERY
HARVARD MEDICAL SCHOOL








Introduction

This past year, the Orthopaedic Department at Children’s Hospital Boston had another fantastic year, filled with challenges, accomplishments and changes. From 2008-2009, our service continued to grow at a rate of approximately 5% in both surgical volume and ambulatory visits. Education of fellows, residents and medical students continued with the added stresses of the 80-hour work week, migration of cases to satellite facilities and ever-increasing demands upon time. Our research program has expanded, both in the clinical and basic science area. Perhaps most significant of all, is the appointment of Peter Waters as the Chief of Clinical Orthopaedic Surgery at our hospital.

DEPARTMENT LEADERSHIP

Let me begin with the change in leadership. Dr. Waters has been a hand and upper extremity surgeon here at Children’s Hospital since 1988. He has become a national leader in pediatric orthopaedic surgery and has been a major contributor to various committees and administrative functions within the hospital. At the same time, he has been an outstanding educator and clinical researcher. His promotion to Professor at Harvard Medical School occurred in 2005. I was privileged to be able to appoint Peter to the position of Chief of Clinical Orthopaedic Surgery, as my role within the hospital has changed somewhat. I took over as the Surgeon-in-Chief at Children’s and am spending more time in administrative duties. Dr. Waters has been responsible in the past for the outpatient program and the move to be in charge of the entire clinical program and education effort was a small step for Peter but carries with it a major benefit for our department. He along with Young-Jo Kim and Don Bae are leading the educational effort of the residents at this time, and I must say that both our interest and reputation in resident, fellow and medical student education remain intact and, if anything, enhanced.

TEACHING PROGRAM

As always, education is a major part of our mission and there is no change in emphasis, despite clinical demands. We continue to have six Harvard residents in their third year, complemented by one Dartmouth resident and one Lenox Hill resident. In addition to the resident housestaff, there are three orthopaedic fellows, three Sports Medicine orthopaedic fellows, a hand fellow, a tumor fellow and an adolescent/young adult hip fellow. Tremendous effort has been put forth to ensure that the fellows complement the education of the residents and that work is split equitably. We attempt to ensure that each resident has sufficient length of rotation and exposure to attendings so that educational benefit and operative experience is maximized. This remains a bit of a challenge as it does mean that all residents cannot rotate with all staff. Surprisingly, we have 24 orthopaedic surgeons at this time on staff at Children’s Hospital Boston. Balancing the duties of residents and fellows is Young- Jo Kim’s responsibility and he does a masterful job at it.

The conference schedule remains much the same as it has in the past, with the Fellows’ Conference on Monday mornings, didactic lectures in pediatric orthopaedics and fractures on Tuesday and Friday. There is also Grand Rounds with all hospitals on Wednesday morning. The Chief’s Conference or case discussion conference which had previously been held on Thursday is supplanted by an Indications Conference, Journal Club or M&M Conference.

The effort to have pre-operative patients evaluated by residents continues but has become much more difficult to achieve. In order for residents to gain information about pre-operative patients, cases are assigned well in advance of time of surgery. An electronic medical record system with a PACS imaging system facilitates patient information retrieval and education. Indications Conference continues on a weekly basis but discussion with individual attendings is the key to proper pre-operative planning. We are divided into 10 clinical programs such as Trauma, Adolescent/Young Adult Hip, Spine, Sports Medicine, Hand and Upper Extremity, etc. Many of these clinical programs hold indications conferences separately, facilitating subspecialty education within pediatric orthopaedics.

The night float system for residents has been put into place to prevent 80-hour work week violations and this appears to be working reasonably well. Residents rotate approximately 3 weeks at a time as the night trauma resident from 7PM to 7AM.

One of the highlights of our educational program each year is the David Grice Visiting Professor; this year we had an outstanding visit with Kerr Graham from Melbourne, Australia. Dr. Graham is an expert in cerebral palsy and has done much to correlate functional outcomes with surgical expectations and indications in CP patients. He is also an expert in gait evaluation relative to cerebral palsy and surgical decision making. During Kerr’s week-long visit, there was a multi-disciplinary course for primary care physicians which was exceedingly well attended, under the direction of Dr. Brian Snyder and Dr. Travis Matheney. Our Grice Lecture Program consisted of one full day of lectures and research talks in the morning, with case presentation from the residents and discussion in the afternoon. Kerr spent 4 days in the ambulatory clinics and the operating room, evaluating patients, participating in resident and attending conferences and provided much to our educational program. We are fortunate to have this endowed professorship to enrich our academic environment each year. We have an ongoing relationship with Melbourne which is multi-faceted. One of our current fellows, Jit Balakumar, is from Melbourne; Travis Matheney had a month-long visit to Melbourne to look at cerebral palsy treatment; Mark Sullivan had an extensive visit with us last year. We are hoping to have an ongoing exchange program facilitating pediatric orthopaedic education of both staff and residents between our institutions.

Don Bae has taken over the CORE educational program for the Harvard Combined Orthopaedic Residency and will be arranging all of the lectures in this comprehensive didactic educational program. The CORE conference program is a major contributor towards the didactic education of the residents, ensuring improved performance on both OITE and Board examination. Don, as all of you know, is an outstanding educator, teacher and pediatric upper extremity surgeon.

With respect to medical student education, Dr. Timothy Hresko has done an excellent job of coordinating the staff for medical student teaching. We continue to have third and fourth year students rotating through the service, as well as a number of students participating in research experiences in the first and second years. As the medical school program has evolved to include a focused research project during the four years of medical school, more students are available and interested in developing research interests during their medical school years. We have two areas of research activity in which the medical students can be involved. The first is the basic science laboratory under the direction of Matt Warman, MD and the other is a clinical research effort through the Clinical Effectiveness Unit in our department. The research lab is a musculoskeletal lab with a genetics bent. They are working on mechanisms of bone formation and degradation, joint lubrication, articular cartilage degradation and finally, a number of musculoskeletal genetic conditions. Matt Warman is a Howard Hughes investigator with an appointment both in Genetics and Orthopaedic Surgery. Dr Melvin Glimcher remains active in the bone mineralization laboratory, looking at structure of bone and mechanisms of calcification. We have welcomed both residents and medical students into the lab and a number of have been productive in this venue.

CLINICAL PROGRAM DEVELOPMENT

The past year has brought with it tremendous development of the clinical program in Waltham where we have a small inpatient unit and an 8,000 square foot ambulatory area with seven pods for orthopaedic patient ambulatory visits. Complemented by four operating rooms and all necessary imaging modalities, we can provide full orthopaedic care in the suburban setting, just as we provide in the Longwood Campus. With free parking and pleasant surroundings in Waltham, one would think that we’d have trouble attracting people to the Longwood Campus. Surprisingly, the Longwood Campus remains as packed as ever, despite marked growth in the Waltham area. Our Waltham ambulatory setting has a capacity for about 30,000 ambulatory visits and after two years of operation, we are just shy of 20,000 annual visits.

As the surgical volume continues to increase, it will be necessary for us to move residents and fellows from Longwood to the Waltham setting. This will be necessary in order to have an educational program which includes small cases as well as the hip, spine, brachial plexus and tumor repairs commonly seen at the main campus which cannot be moved to a satellite setting.

PEDIATRIC ORTHOPAEDIC FELLOWS

This year, we have three fellows in our ACGME-approved fellowship in Pediatric Orthopaedics. The fellows are Brian Brighton, MD who did his residency at Cleveland Clinic; Jonathan Schoenecker, MD, PhD from Vanderbilt; and Jitendra Balakumar, MBBS, from Melbourne, Australia. Brian’s interest is in general pediatric orthopaedics and spine and he will go to Carolina Medical Center starting in the fall. Jon Schoenecker came to us from Vanderbilt and will return to practice pediatric orthopaedics and lead a basic science research lab. Jit Balakumar will return to Melbourne for the practice of pediatric orthopaedic surgery and spine surgery in an academic setting.

Next year, two of our orthopaedic residents, Coleen Sabatini and Mike Glotzbecker, are entering into pediatric orthopaedic fellowships. Mike will stay here as a fellow with us and Coleen who has a long-term interest in being in Southern California will be going to LA Children’s Hospital. Both are outstanding residents and will be top pediatric orthopaedic surgeons, I predict.

Our fellowship program is complemented by Sports fellows, both primary care and orthopaedics. An upper extremity fellow from the Combined Program at the Brigham and Women’s Hospital and a tumor fellow from the combined program in Orthopaedic Oncology at BIDMC and MGH.

PROMOTIONS

Over the past year, Dr. Timothy Hresko was promoted to Associate Professor of Orthopaedic Surgery. His interests remain primarily in spine surgery, with his research activity focused on idiopathic scoliosis. He has a secondary interest in medical student education and has led our medical student clinical and research program over the last 15 years.



NEW STAFF

Dr Yi-Meng Yen has joined our staff in pediatric orthopaedics and Sports Medicine. He completed a fellowship with us in pediatric orthopaedic surgery, following a Sports Medicine fellowship at Steadman Hawkins Clinic in Vail, Colorado. His residency was at UCLA, as was his medical school education. He is a great addition to the department. The Division of Sports Medicine has grown remarkably under the leadership of Drs. Micheli and Kocher. We have 5 full-time orthopaedic Sports Medicine physicians and a busy cadre of primary care Sports Medicine docs.



OTHER STUFF

For those of you who remember the Orthopaedic Offices on Hunnewell 2 in the old Children’s Hospital building, circa 1914, not much has changed; new staff continues to be added to old space, bunking 2 or even 3 to an office. The administrative assistants’ offices often hold three people. Our library, which could no longer hold expanded staff and residents, was remodeled a bit this year. We took the novel approach of tearing out the bookcases in order to increase the size of the room and provide a bench for a second row of seating around the conference table. This allows us to increase the numbers of attendees at conference to approximately 25. The conference room looks great with the addition of computers and literature search capabilities. Traditional textbooks and journals are not nearly so important to education as computers and Internet capability. No longer do we have the pull-down screen but a large flat screen monitor on which lectures and images project wonderfully. If we can get the Red Sox on the screen in the conference room, it will be perfect.

Dr. Hall continues to thrive and comes in once a month for a visit and to check his mail. Dr. Paul Griffin is living in The Cliffs, a golf community in the mountains outside of Greenville, South Carolina.

If you are in the area, stop by for a visit. While we remain a busy, over-committed group, there is always time for visits from old friends and new ideas into these old walls.





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