Daniel J Sucato

Texas Scottish Rite Hospital for Children, Texas City, Texas, United States

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Publications (119)284.34 Total impact

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    ABSTRACT: Idiopathic scoliosis (IS) is a common paediatric musculoskeletal disease that displays a strong female bias. By performing a genome-wide association study (GWAS) of 3,102 individuals, we identify significant associations with 20p11.22 SNPs for females (P ¼ 6.89 Â 10 À 9) but not males (P ¼ 0.71). This association with IS is also found in independent female cohorts from the United States of America and Japan (overall P ¼ 2.15 Â 10 À 10 , OR ¼ 1.30 (rs6137473)). Unexpectedly, the 20p11.22 IS risk alleles were previously associated with protection from early-onset alopecia, another sexually dimorphic condition. The 174-kb associated locus is distal to PAX1, which encodes paired box 1, a transcription factor involved in spine development. We identify a sequence in the associated locus with enhancer activity in zebrafish somitic muscle and spinal cord, an activity that is abolished by IS-associated SNPs. We thus identify a sexually dimorphic IS susceptibility locus, and propose the first functionally defined candidate mutations in an enhancer that may regulate expression in specific spinal cells.
    Nature Communications 04/2015; 6. DOI:10.1038/ncomms7452 · 10.74 Impact Factor
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    ABSTRACT: To analyze outcomes of adolescents treated with a periacetabular osteotomies (PAO) with a minimum of 2 years of follow-up. Patients undergoing a PAO for adolescent hip dysplasia were analyzed preoperatively, 1 and 2 years postoperatively. In 32 dysplastic hips significant improvement was seen in all radiographic parameters. Gait speed, hip flexion pull-off power, and hip abductor moment impulse were unchanged postoperatively, whereas strength was maintained in 85% (abduction) and 95% (flexion). The Harris Hip Score increased from 67.1 to 77.9 to 81.3 at 1 and 2 years, respectively. Ganz PAO is effective in correcting dysplasia in adolescents radiographically and functionally.
    Journal of Pediatric Orthopaedics B 03/2015; 24(2):99-105. DOI:10.1097/BPB.0000000000000148 · 0.66 Impact Factor
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    ABSTRACT: Introduction In Lenke 2 curves, there are conflicting data when to include the PTC into the fusion. Studies focusing on Lenke 2 curves are scant. The number of patients with significant postoperative shoulder height difference (SHD) or trunk shift (TS) is as high as 30 % indicating further research. Therefore, the purpose of the current study was to improve understanding of curve resolution and shoulder balance following surgical correction of Lenke 2 curves as well as the identification of radiographic parameters predicting postoperative curve resolution, shoulder and trunk balance in perspective of inclusion/exclusion of the proximal thoracic curve (PTC). Methods This is a retrospective study of a 158 Lenke 2 curves. Serial radiographs were analyzed for the main thoracic curve (MTC), PTC, and lumbar curve (LC), SHD, clavicle angle (CA), T-1 tilt, deviation of the central sacral vertical line (CSVL) off the C7 plumb line.Patients were stratified whether the PTC was included in the fusion (+PTC group, n = 60) or not (−PTC group, n = 98). Intergroup results were studied. Compensatory mechanisms for SHD were studied in detail. Adding-on distally was defined as an increase of the lowest instrumented vertebra adjacent disc angle (LIVDA) >3°. Stepwise regression analyses were performed to establish predictive radiographic parameters. Results At follow-up averaging 24 months significant differences between the +PTC and –PTC group existed for the PTC (24° vs 28°, p p 5° (27 vs 53 %, p p = .04). The number of patients with a new trunk shift (CSVL > 2 cm) was 9 (6 %): 7 in the −PTC vs 2 in the +PTC group (p = .03). Utilization of compensatory mechanisms (99 vs 83 %, p p p = .02). Statistics identified a preoperative ‘left shoulder up’ (p p = .03) predictive for follow-up SHD ≥1.5 cm. A statistical model only for the –PTC group showed 9 parameters highly predictive for a follow-up SHD ≥1.5 cm with highest prediction strength for a PTC >40° (p = .01), a preoperative ‘left shoulder up’ (p p = .02). To account for baseline differences between the +PTC and –PTC groups, 49 matched-pairs were studied. Postoperative differences remained significant between the +PTC and –PTC groups for the PTC (p p = .03) and the rate of loss of MTC >5° (p Conclusion Prediction of a successful surgical outcome for Lenke 2 curves depends on multiple variables, in particular a preoperative left shoulder up, preoperative PTC >40°, MTC correction, and surgical approach. Shoulder balance is not significantly different whether the PTC is included in the fusion or not. But, powerful compensation mechanisms utilized to balance shoulder in the –PTC group can impose changes of trunk alignment, main and compensatory lumbar curves.
    European Spine Journal 02/2015; DOI:10.1007/s00586-015-3772-x · 2.47 Impact Factor
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    ABSTRACT: Surgical site infection is a serious complication of posterior spinal fusion for neuromuscular scoliosis, with a reported prevalence of 6% to 24%. A single-institution experience over a thirty-year period was reviewed to determine the prevalence of surgical site infection after posterior spinal fusion for neuromuscular scoliosis, and to identify patient and treatment-related risk factors. Our retrospective review included all patients treated with posterior spinal fusion (alone or in combination with an anterior procedure) for neuromuscular scoliosis from 1980 to 2009 and followed for a minimum of two years. Univariate and multivariate statistical analysis was performed to identify significant risk factors for occurrence of deep surgical site infection (p < 0.05). The study included 428 patients with an average duration of follow-up of 4.9 years. The mean Cobb angle was 74.3°. Most (74%) were treated with posterior spinal fusion alone. Deep infection developed in forty-four patients (10.3%); 57% of the infections occurred within three months after the surgery and 73%, within twelve months. Nearly half (45%) of the infections were polymicrobial; 59% of the organisms were gram-positive and 41% were gram-negative. Implant removal was required in 58% of the patients. Surgical site infection was more frequent from 1980 to 1989 (20.3%) than it was from 1990 to 2009 (8.4%) (odds ratio [OR] = 2.8, p = 0.01 in univariate analysis). Surgical site infection was more common in patients with spina bifida (21.5%) than in those with other diagnoses (8.3%) (OR = 3.0, p = 0.001). Other patient factors associated with surgical site infection were a body mass index (BMI) of >25 kg/m(2) (OR = 2.4, p = 0.04) and incontinence (OR = 2.4, p = 0.009). Treatment factors associated with surgical site infection were inadequate prophylactic antibiotic dosing (cefazolin ≤20 mg/kg) (OR = 3.3, p = 0.0002), length of fusion (p = 0.002), pelvic fixation (OR = 2.4, p = 0.04), length of hospital stay (p = 0.005), and other complications (OR = 3.2, p = 0.0003). Drain output (p = 0.04) and lower hemoglobin levels (p = 0.008) were significantly associated with surgical site infection in patients with spina bifida, and drain use (superficial to the fascia) was protective in those without spina bifida (OR = 0.5, p = 0.046). This study identified modifiable factors, especially antibiotic dosing and drain use, associated with surgical site infection in patients with neuromuscular scoliosis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
    The Journal of Bone and Joint Surgery 12/2014; 96(24):2038-48. DOI:10.2106/JBJS.N.00277 · 4.31 Impact Factor
  • Daniel J Sucato, Adriana De La Rocha
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    ABSTRACT: The patient with an unstable slipped capital femoral epiphsyis poses a challenging problem to the treating physician to improve the position of the displaced epiphysis to avoid femoroacetabular impingement without developing avascular necrosis (AVN)-a potentially devastating complication. Although the standard operative procedure of in situ pinning following an incidental reduction while positioning the patient on the table, has been the mainstay of treatment in North America, other viable options are available including a surgical dislocation approach to the hip followed by a modified Dunn osteotomy with control of the retinacular vessels, reduction of the epiphysis, and internal fixation with pins or screws. Although technically demanding, this approach offers an opportunity to reduce the epiphysis to avoid femoroacetabular impingement, and limit the possibility for the development of AVN. The early results for this procedure are promising with all studies demonstrating excellent reduction of the epiphysis and an overall lower incidence of AVN when compared with in situ pinning.
    Journal of pediatric orthopedics 10/2014; 34 Suppl 1 Supplement:S18-S24. DOI:10.1097/BPO.0000000000000297 · 1.43 Impact Factor
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    ABSTRACT: A traumatic hip dislocation in the pediatric patient is a rare but potentially catastrophic injury. The purpose of this study was to review our early clinical results and radiographic morphology of hips treated with a surgical hip dislocation (SHD) approach for intra-articular hip pathology resulting from traumatic instability in pediatric and adolescent patients.
    Journal of pediatric orthopedics 09/2014; DOI:10.1097/BPO.0000000000000316 · 1.43 Impact Factor
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    ABSTRACT: Questions remain as to the effect of pedicle screws on spinal canal development in young children. The purpose of this study was to determine the effects of unilateral placement of dual screws across the neurocentral synchondrosis on spinal canal development as assessed with histological analysis and measurement of the canal dimensions in an immature pig model.
    The Journal of Bone and Joint Surgery 09/2014; 96(17):e146. DOI:10.2106/JBJS.M.01365 · 4.31 Impact Factor
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    ABSTRACT: Study Design Retrospective review of multicenter data set with adolescent idiopathic scoliosis (AIS) patients with at least 2 years of follow-up after posterior spinal instrumentation and fusion (PSIF). Objectives The purpose of this study is to investigate risk factors for coronal decompensation 2 years after PSIF for AIS. Summary of Background Data Coronal decompensation is a potential complication of spinal instrumentation for AIS. This can result in problems requiring revision surgery. Methods Demographic, clinical, and radiographic measures were reviewed on 890 identified patients. Coronal decompensation was defined as a change farther away from midline from 6 weeks postoperatively to 2 years in any one of the following radiographic parameters: change in coronal balance >2 cm; change in coronal position of the lowest instrumented vertebra (LIV) >2 cm; change in thoracic trunk shift >2 cm; or change in LIV tilt angle >10°. Patients with decompensation were compared to those without. The relationship between the LIV and lowest end vertebra (LEV) was examined as an independent variable. Results Two years postoperation, 6.4% (57/890) of patients exhibited coronal decompensation. Multivariate regression revealed that decompensated patients were twice as likely to be male, have lower preoperative Risser score, and lower percentage major curve correction. The relationship between the LIV and LEV as well as quality of life surveys were not significantly different between decompensated and nondecompensated patients at 2 years. Conclusions Two years after PSIF, 6.4% of patients with AIS exhibit radiographic coronal decompensation. Although this study did not demonstrate a significant association between the relationship of LIV and LEV and decompensation 2 years postoperation, results of this study indicate that skeletal immaturity, male gender, and less correction of the major curve may be related to higher rates of coronal decompensation.
    09/2014; 2(5):380–385. DOI:10.1016/j.jspd.2014.05.001
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    ABSTRACT: Study Design Consensus-based creation of a checklist and guideline. Objective To develop a consensus-based checklist to guide surgeon responses to intraoperative neuromonitoring (IONM) changes in patients with a stable spine and to develop a consensus-based best practice guideline for IONM practice in the United States. Summary of Background Data Studies show that checklists enhance surgical team responses to crisis situations and improve patient outcomes. Currently, no widely accepted guidelines exist for the response to IONM changes in spine deformity surgery. Methods After a literature review of risk factors and recommendations for responding to IONM changes, 4 surveys were administered to 21 experienced spine surgeons and 1 neurologist experienced in IONM. Areas of equipoise were identified and the nominal group process was used to determine items to be included in the checklist. The authors reevaluated and modified the checklist at 3 face-to-face meetings over 12 months, including a period of clinical validation using a modified Delphi process. The group was also surveyed on current IONM practices at their institutions. This information and existing IONM position statements were used to create the IONM best practice guideline. Results Consensus was reached for the creation of 5 checklist headings containing 26 items to consider in the response to IONM changes. Consensus was reached on 5 statements for inclusion in the best practice guideline; the final guideline promotes a team approach and makes recommendations aimed at decreasing variability in neuromonitoring practices. Conclusions The final products represent the consensus of a group of expert spine surgeons. The checklist includes the most important and high-yield items to consider when responding to IONM changes in patients with a stable spine, whereas the IONM guideline represents the group consensus on items that should be considered best practice among IONM teams with the appropriate resources.
    09/2014; 2(5):333–339. DOI:10.1016/j.jspd.2014.05.003
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    ABSTRACT: A comprehensive evaluation of hip radiographs in the young adult with hip pain has become increasingly complex and time consuming. The interobserver reliability of manually performed measurements of femoroacetabular impingement, including the alpha angle, has been questioned. Methods to improve the reliability of a radiographic evaluation may increase the clinical utility of these parameters.
    The American Journal of Sports Medicine 08/2014; 42(10). DOI:10.1177/0363546514542797 · 4.70 Impact Factor
  • Adriana De La Rocha, Anna McClung, Daniel J. Sucato
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    ABSTRACT: Study Design Retrospective. Summary of Background Data Previous studies have reported the correlation of body mass index (BMI) with non-spine surgical outcomes; however, only a few reviewed the correlation of BMI to outcomes after spine surgery. Objectives To review the influence of preoperative BMI on the follow-up clinical and functional outcomes after posterior-only fusion (PSF) and instrumentation for adolescent idiopathic scoliosis in a larger patient cohort. Methods Retrospective review of a consecutive series of patients treated with PSF for adolescent idiopathic scoliosis from 2002 to 2009 at a single institution. There were 3 categories: underweight (UW), normal weight (NML), and overweight (OW). Percent correction of the major curve was collected at 2 years postoperatively and patient outcome scores were analyzed preoperatively and at 2 years postoperatively. Differences between groups were analyzed using analysis of variance, with p < .05. Results A total of 459 patients at an average age of 15.0 years (range, 10.0–21.3 years) treated with PSF instrumentation were included. At 2 years, all groups achieved and maintained equal percent correction with no differences between groups. Regarding preoperative Scoliosis Research Society (SRS) outcome scores, OW patients reported more pain than NML (p = .002) and UW patients (p < .001) despite less reported activity than for the NML (p = .033) and UW groups (p = .005). The total SRS score was also lower in the OW patients compared with NML (p = .009) and UW patients (p = .002). At 2 years, the OW group reported more pain than the UW (p = .031) and NML groups (p = .018), lower mental scores (p = .011) and lower SRS total scores (p = .005) than the NML group. Conclusions At follow-up, preoperative overweight adolescents reported more pain and lower mental, activity, and appearance domain scores after surgery than UW and NML patients despite equal percent curve correction. This information may help the surgeon with preoperative counseling of OW patients by stressing that their own assessment of outcome is influenced by BMI, which may help promote a healthy weight management program in this patient group.
    05/2014; 2(3):208–213. DOI:10.1016/j.jspd.2013.12.005
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    ABSTRACT: Adolescent idiopathic scoliosis (AIS) is a common rotational deformity of the spine that presents in children worldwide, yet its etiology is poorly understood. Recent genome-wide association studies (GWAS) have identified a few candidate risk loci. One locus near the chromosome 10q24.31 LBX1 gene (OMIM #604255) was originally identified by a GWAS of Japanese subjects and replicated in additional Asian populations. To extend this result, and to create larger AIS cohorts for the purpose of large-scale meta-analyses in multiple ethnicities, we formed a collaborative group called the International Consortium for Scoliosis Genetics (ICSG). Here, we report the first ICSG study, a meta-analysis of the LBX1 locus in six Asian and three non-Asian cohorts. We find significant evidence for association of this locus with AIS susceptibility in all nine cohorts. Results for seven cohorts containing both genders yielded P=1.22×10-43 for rs11190870, and P=2.94×10-48 for females in all nine cohorts. Comparing the regional haplotype structures for three populations, we refined the boundaries of association to a ∼25 kb block encompassing the LBX1 gene. The LBX1 protein, a homeobox transcription factor that is orthologous to the Drosophila ladybird late gene, is involved in proper migration of muscle precursor cells, specification of cardiac neural crest cells, and neuronal determination in developing neural tubes. Our results firmly establish the LBX1 region as the first major susceptibility locus for AIS in Asian and non-Hispanic white groups, and provide a platform for larger studies in additional ancestral groups.
    Journal of Medical Genetics 04/2014; DOI:10.1136/jmedgenet-2013-102067 · 5.64 Impact Factor
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    The Journal of Bone and Joint Surgery 03/2014; 96(5):e38. DOI:10.2106/JBJS.M.00398 · 4.31 Impact Factor
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    ABSTRACT: Study Design. Retrospective review of prospectively collected data.Objective. To determine whether anchor density is associated with curve correction and patient-reported outcomes.Summary of Background Data. There is limited information as to whether anchor density affects the results of adolescent idiopathic scoliosis (AIS) surgery.Methods. 952 AIS patients met inclusion criteria (Lenke 1, 2, and 5 curves) with predominantly screw constructs (# screws/# total anchors > 75%). Anchor density was defined as # of screws, hooks, and wires per level fused, with less than 1.54 considered low density. ANCOVA analysis was undertaken to determine association of anchor density with% curve correction, SRS, and SAQ scores, controlling for flexibility, fusion length, demographics, and surgeon.Results. High compared to low anchor density was associated with increased% curve correction in Lenke 1 curves at 1-year (69% vs. 66% correction, p = 0.0022), controlling for% pre-operative curve flexibility, length of fusion, and gender (model, p<0.0001). Similar associations held at 2-year follow-up and for Lenke 2 curves. Decreased thoracic kyphosis was found with increased anchor density for Lenke 1 and 2 curve patterns. There were no associations found between anchor density and Lenke 5 curves.For Lenke 1 curve patterns at 2-years postoperatively, in the high vs. low anchor density cohorts, there were statistically higher SRS Activity (4.3 vs. 4.2, p = 0.019), Appearance (4.3 vs. 4.1, p = 0.0005), Satisfaction (4.5 vs. 4.3, p = 0.028), and Total Scores (4.3 vs. 4.2; p = 0.024). Similarly, the SAQ Appearance score at 1-year similarly was improved in the high anchor density group (high: 14.1 vs. low: 15.0, p = 0.03) for Lenke 1 curve patterns only.Conclusion. For Lenke 1 and 2 curve patterns, improved% correction of major coronal curve was noted in the high screw density cohort. Although statistical significance was reached, it is unclear if screw density resulted in clinically significant differences in patient-reported outcomes.
    Spine 01/2014; 39(7). DOI:10.1097/BRS.0000000000000204 · 2.45 Impact Factor
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    The Journal of Bone and Joint Surgery 12/2013; 95(23):e1851-8. DOI:10.2106/JBJS.L.01620 · 4.31 Impact Factor
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    ABSTRACT: There are no guidelines for when surgeons should allow patients to return to sports and athletic activities after spinal fusion for adolescent idiopathic scoliosis (AIS). Current recommendations are based on anecdotal reports and a survey performed more than a decade ago in the era of first/second-generation posterior implants. To identify current recommendations for return to sports and athletic activities after surgery for AIS. Questionnaire-based survey. Adolescent idiopathic scoliosis after corrective surgery. Type and time to return to sports. A survey was administered to members of the Spinal Deformity Study Group. The survey consisted of surgeon demographic information, six clinical case scenarios, three different construct types (hooks, pedicle screws, hybrid), and questions regarding the influence of lowest instrumented vertebra (LIV) and postoperative physical therapy. Twenty-three surgeons completed the survey, and respondents were all experienced expert deformity surgeons. Pedicle screw instrumentation allows earlier return to noncontact and contact sports, with most patients allowed to return to running by 3 months, both noncontact and contact sports by 6 months, and collision sports by 12 months postoperatively. For all construct types, approximately 20% never allow return to collision sports, whereas all surgeons allow eventual return to contact and noncontact sports regardless of construct type. In addition to construct type, we found progressively distal LIV resulted in more surgeons never allowing return to collision sports, with 12% for selective thoracic fusion to T12/L1 versus 33% for posterior spinal fusion to L4. Most respondents also did not recommend formal postoperative physical therapy (78%). Of all surgeons surveyed, there was only one reported instrumentation failure/pullout without neurologic deficit after a patient went snowboarding 2 weeks postoperatively. Modern posterior instrumentation allows surgeons to recommend earlier return to sports after fusion for AIS, with the majority allowing running by 3 months, noncontact and contact sports by 6 months, and collision sports by 12 months.
    The spine journal: official journal of the North American Spine Society 10/2013; DOI:10.1016/j.spinee.2013.06.035 · 2.80 Impact Factor
  • The Spine Journal 09/2013; 13(9):S37-S38. DOI:10.1016/j.spinee.2013.07.120 · 2.80 Impact Factor
  • The Spine Journal 09/2013; 13(9):S59. DOI:10.1016/j.spinee.2013.07.169 · 2.80 Impact Factor
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    ABSTRACT: Study Design Longitudinal cohort. Objectives To determine the responsiveness of the Spinal Appearance Questionnaire (SAQ) in patients with adolescent idiopathic scoliosis (AIS) undergoing surgical correction of the deformity. Summary of Background Data The SAQ has been found to be a valid and reliable measure in patients with AIS. A recently published factor analysis and scoring system has been shown to be applicable to all Lenke types and had greater correlation to the curve magnitude than the Scoliosis Research Society (SRS) Appearance and Total score. Methods From a prospective multicenter database, 126 AIS patients who underwent correction of the spinal deformity with complete SAQ and SRS-22 Revised data at baseline and 2-year follow-up were identified. Discriminative properties of the SAQ domains (Expectations, Appearance, and Total) and SRS domains (Appearance, Activity, Pain, Mental, Satisfaction, and Total) were compared by computing the effect size (ES) and the standardized response mean (SRM). Results The SAQ Total had the largest ES (1.8) and SRM (1.5). This was followed by the SAQ Appearance, with an ES of 1.7 and SRM of 1.4; and the SAQ Expectations, with an ES of 1.5 and SRM of 1.2. Among the different SRS domains, only the Appearance (ES = 1.2, SRM = 1.1), Satisfaction (ES = 0.8, SRM = 0.6), and Total scores (ES = 0.8, SRM = 0.9) had effect sizes that were considered large. The SRS Mental domain had a moderate effect size (ES = 0.3, SRM = 0.3), whereas the Activity (ES = 0.0, SRM = 0.0) and Pain (ES = 0.2, SRM = 0.2) domains had small effect sizes. Conclusions The SAQ is sensitive and responsive to change, as evidenced by the large effect size for both domain and the Total score. The effect sizes are larger than those for any of the SRS domains, including Appearance and Total scores.
    09/2013; 1(5):328–338. DOI:10.1016/j.jspd.2013.06.001

Publication Stats

1k Citations
284.34 Total Impact Points


  • 2002–2015
    • Texas Scottish Rite Hospital for Children
      Texas City, Texas, United States
  • 2013–2014
    • Washington University in St. Louis
      San Luis, Missouri, United States
    • Walter Reed National Military Medical Center
      Washington, Washington, D.C., United States
    • Loyola University Medical Center
      Maywood, Illinois, United States
  • 2011
    • Norton Healthcare
      Louisville, Kentucky, United States
  • 2003–2011
    • University of Texas Southwestern Medical Center
      • Department of Orthopaedic Surgery
      Dallas, TX, United States
  • 2003–2009
    • Shriners Hospitals for Children
      Tampa, Florida, United States
  • 2007
    • University of Kentucky
      Lexington, Kentucky, United States
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2006
    • Boston Children's Hospital
      • Department of Orthopaedic Surgery
      Boston, MA, United States
  • 2004–2005
    • University of Texas at Dallas
      Richardson, Texas, United States