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

Introduction

This academic year 2006-2007 was a year of continued growth for the Orthopaedic Department at Children’s Hospital Boston. We added three new staff in our clinical program, a new director of basic science research, and established a major new site of service in Waltham. In doing this, as always, we strengthened our teaching program for the residents, fellows, and students, as well as providing greater opportunity for clinical practice for the staff. In addition to the normal daily conferences providing the bulk of our teaching program, Grice Day in the fall and a festschrift in honor of Dr. Glimcher were highlights of our teaching program.

Our clinical program grew at over 3% last year, which was quite a feat. This was really secondary to the addition of three staff members; Dr. Gregory Melkonian, Dr. Travis Matheney, and Dr. Samantha Spencer. Samantha Spencer did her undergraduate work and attended medical school at the University of Michigan prior to coming to the Harvard Combined Orthopaedic Residency Program. After completing residency and fellowship with us, she joined the staff with a special interest in metabolic bone disease, bone dysplasias, and osteogenesis imperfecta. She spent time visiting Francois Fassier in Montreal, enhancing her education in osteogenesis imperfecta in both medical and surgical treatment. Travis Matheney was a medical student at Dartmouth prior to coming to the Harvard Orthopaedic Program. After expressing an interest in pediatric orthopaedics, cerebral palsy and hip problems, he entered the fellowship program here at Children’s. He supplemented his education with a trip to Australia and New Zealand visiting Kerr Graham, Hamish Crawford and Rich Nichol. I am certain that, in addition to the orthopaedic perspective, he gained quite an education while spending two months down under. Finally, Greg Melkonian came to us from his practice in Concord, New Hampshire. He has been by training a veterinarian and an orthopaedic surgeon, having completed the program at the University of Vermont. He did advanced training at Rancho Los Amigos Hospital. He has an interest and vast experience in the management of children with neuromuscular diseases. Susan Mahan has completed her Masters Degree in Public Health and has moved from part-time to full-time member of our department. She has had a concentrated interest in epidemiology as well as clinical research based on large database analysis.

In addition to the expansion of our clinical staff, our basic science program is developing at a rapid rate. The addition of Dr. Matt Warman was a major step, of which I am quite proud. After an internal review of our laboratory, the committee felt that the addition of expertise in Genetics and movement in this direction from a mineralization and bone structure lab was critical to future funding and consistent with the direction of musculoskeletal science. I structured a search in conjunction with the Department of Genetics at Harvard Medical School with the assistance of Dr. Phil Leder and Dr. Cliff Tabin to find the best fit to become the director of our lab, along with the appointment of the Ormandy Professor of Genetics in Orthopaedic Surgery at Harvard Medical School. Without a doubt, Dr. Warman was the most qualified and most exciting of the candidates interviewed and joined our staff this year. He is a Howard Hughes investigator who had previously worked with me in the Bone Dysplasia Clinic in the 1980s and early 90s prior to leaving Harvard for Case Western Reserve University. He returns with a national reputation for his expertise in musculoskeletal genetics with great enthusiasm to move the lab forward. Both Dr. Glimcher and I welcome him into his new role in the lab.

Dr. Martha Murray and Dr. Young-Jo Kim have had great success in the basic science arena over the past year. Dr. Murray has been funded by the NIH for her work involving intraarticular healing. She has, as many of you know, dedicated much of her investigative career to the repair of the anterior cruciate ligament and facilitating its healing. With significant success in early results, she is moving forward in animal and hopefully human studies to bring this technology into the clinical arena.

Dr. Kim was the recipient of a Kappa Delta Award this year, along with Dr. Martha Gray and Dr. Deborah Burstein, for his investigations in imaging of articular cartilage. Dr. Kim’s portion of the study related to the use of MR of articular cartilage to determine the outcome of redirectional osteotomies of the proximal femur and acetabulum. Dr. Kim also is the recipient of an OREF Career Development Award, which should move his basic science career forward exponentially.

To accommodate the growing demands for pediatric orthopaedic services, as well as deal with the congestion of the Longwood Medical area, Children’s Hospital Boston has developed a second site of service in Waltham, Massachusetts. The Waltham Hospital was purchased about two years ago and has been totally remodeled into a modern medical facility. There are approximately 300,000 square feet of space, including an inpatient unit, outpatient infusion unit, an ambulatory area and six operating rooms. The orthopaedic area at Waltham consists of 7,500 square feet of exam space with a cast room and modern state-of-the art facilities where seven doctors at one time can see patients in high tech pods. Parking is free, which has led to great excitement among our patients and further demands for service in the suburbs. Sports, Hand and Upper Extremity, and General Orthopaedics will be emphasized in this new setting, offering a full array of ambulatory and a more limited set of surgical services. In order to function in this new setting with a limited number of residents and fellows, we have added two physicians’ assistants to complement our four nurse practitioners and provide both surgical assistance as well as pre-operative and post-operative ambulatory care. The physicians’ assistants, Estee Gelbard and Laura Higgins are settling in nicely and are both a benefit to the clinical service as well as the educational endeavors of the Orthopaedic Department. While surgical assistance by PAs may seem contrary to the educational mission, to this point it has significantly complemented our ability to provide surgical care. With the PAs working on Wednesday mornings in the Longwood area as well as in the Waltham unit, residents can attend the Core Conference without clinical demands in the hospital. In addition to the two new physicians’ assistants in Orthopaedics, there are two new physicians’ assistants in Sports Medicine, Betsy Gonski and Courtney Peck; and four nurse practitioners in Orthopaedics, Rachel DiFazio, Amanda Burns, Jessica Burns and Cynthia Thompson.

In addition to adding space in response to the demands of patients and pediatricians, we instituted what we call the Orthopaedic Surgeon of the Week or OOW Program. In the OOW Program, an orthopaedic surgeon is on call from 7:00 AM to 7:00 PM, Monday through Friday. Night call is taken by another orthopaedic surgeon. We try to operate on emergency cases until midnight and then hold all cases until the following day. Night call is rotated among the staff in the traditional way. This has improved patient and pediatrician satisfaction significantly with our ability to have patients seen on the day when urgent care is required. The team seeing urgent patients during the day is comprised of the orthopaedic surgeon (OOW), a nurse practitioner or a PA, and a resident or fellow. In this way, daytime emergency surgery is central to the teaching program and augments trauma education for the residents. The changes in staff, facilities, and program allow us to manage increased patient demand without compromising resident education. The rotation for the residents has been changed within our institution in a major way in order to ensure that rotations are sufficiently long to allow trust to build and the resident to see adequate patient follow-up post surgery.

In addition to attempting to alter resident rotations to improve education, our teaching program continues as it has in the past. Monday and Tuesday we have Basic Science, Pediatric Orthopaedics or Fracture Conference; Thursday is Chief’s Conference and Friday is Fellows’ Conference. Grand Rounds occurs every Wednesday. In addition to the normal teaching program, The Grice Lecture was held on November 6, 2006. Marc Asher, a distinguished alumnus of this program was the 20th David Grice Visiting Professor. Dr. Asher completed the program here at Children’s in 1970 and went on to become Department Chairman and Professor at the University of Kansas Medical School and a distinguished spine surgeon nationally and internationally. He spoke on many aspects of scoliosis and the development of instrumentation systems for spinal deformity correction.

This spring, we had a fantastic Basic Science Program in Bone Metabolism as a festschrift for Dr. Melvin Glimcher, who is stepping down at the Director of the Laboratory for Skeletal Disorders. The program included the portrait of Dr. Glimcher in honor of his distinguished career and program below outlines the scientific program held in his honor. The scientific program included trainees, distinguished prior members of the lab, as well as national research colleagues of Dr. Glimcher’s. The lecturers explored the range of bone research from mineralization and structure through genetics. Dr. Glimcher had a 47-year distinguished record of continuous NIH funding for his insights into bone mineralization as well as its collagenous and non-collagen proteins. His continued work within the lab as well as insights into the crystal structure and phosphoproteins of bone will complement the molecular genetic emphasis, which we are now pursuing in the lab.

Resident and fellow education remains central to our mission. In addition to the six Harvard PGY-3 residents on the service at any time, one Lenox Hill resident and one Dartmouth resident rotate at our institution. The Dartmouth affiliation is new this year and we are proud of this association. Our regional affiliation is complemented by this educational endeavor. Drs. Moen and Carney at Dartmouth provide three months of pediatric orthopaedic education for each resident and we provide three months. The educational integration complements the clinical relationship established between our institutions.

In the spring of this year the EPOS Traveling Fellows, Ola Wiig from Norway, Boyan Valentinov from Bulgaria and Andrzej Grzegorzewski from Poland visited Children’s Hospital. Our program consisted of case presentation and discussion, short papers, and most importantly, social contact at dinners. POSNA and EPOS have exchange fellow programs every other year. A number of our prior alumni have participated in this fellowship program and benefited educationally from this opportunity.

After ACGME review, our fellowship program in Pediatric Orthopaedics was accredited for five years. We continue to attract top notch fellows in Pediatric Orthopaedics, as we do in Sports, Hand Surgery, and Tumor Surgery. The three pediatric orthopaedic fellows this year are Tom McPartland, Scott Rosenfeld, and Jennifer Ty. Thomas McPartland is a graduate of Robert Wood Johnson Orthopaedic Program and after completing the fellowship, plans to return to New Jersey and enter practice with Drs. Bowe, Laufer and Therrien, well known to our institution.

Scott Rosenfeld, a graduate of Texas Southwestern Residency Program, where his pediatric orthopaedics was done with Tony Herring and company, will go to Houston, Texas and work as an attending in the orthopaedic program at Texas Children’s Hospital with Jake Weinberg, one of our previous fellows. Jen Ty, the third fellow, is a graduate of the Harvard Combined Orthopaedic Program and will enter the UCSF Hand Program, to pursue a career in pediatric hand surgery in the future.

On a personal note, I have been rather busy with an array of activities ranging from the Children’s Hospital Physicians’ Organization to the American Board of Orthopaedic Surgery. I am now in charge of the recertification written examination, which appears to be a bit of a challenge, as you might guess. Maintaining the proper balance of questions representing basic knowledge that all orthopaedic surgeons should have is not a simple task. Ensuring that satisfactory images are present on the computers for the exams is probably the biggest challenge. I am completing my thirteenth year as Orthopaedic Surgeon-in-Chief at Children’s Hospital. The challenges remain great. Continued clinical growth with staff development, clinical and basic science research, and education all must be emphasized and balanced; I believe that we are succeeding in these areas as well as growing clinical research under our Clinical Effectiveness Unit led by Patty Connell, working with five research assistants. We encourage residents and fellows to participate actively in research during their time at Children’s. Our publication rate remains excellent. Staff is being promoted at a satisfactory rate.








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