Michael J Gardner

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (166)313.44 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The goals of this study were to assess syndesmotic reductions using computerized tomography and to determine whether malreductions are associated with certain injury types or reduction forceps. Prospective cohort. Urban level 1 trauma center. Twenty-seven patients with operatively treated syndesmotic injuries were recruited prospectively. Patients underwent postoperative bilateral computerized tomography of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences of the fibular position within the tibial incisura were measured at several anatomic points and analyzed based on injury type, the presence of posterior malleolar injury, level of fracture, and type of reduction forceps used. On average, operatively treated syndesmotic injuries were overcompressed (fibular medialization) by 1 mm (P < 0.001) and externally rotated by 5° (P = 0.002) when compared with the uninjured extremity. The absence of a posterior malleolar injury and Weber B (OTA 44-B) fractures seemed to have a protective effect against malrotation, but not against overcompression. There was no difference in malreduction based on the type of the clamp used. It is possible, and highly likely based on these data, to overcompress the syndesmosis when using reduction forceps. Care should be taken to avoid overcompression, as this may affect the ankle motion and functional outcomes. To our knowledge, this is the first in vivo series of syndesmotic overcompression. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 09/2015; 29(9):414-419. DOI:10.1097/BOT.0000000000000356 · 1.54 Impact Factor
  • Michael J Gardner · Matthew L Graves · Thomas F Higgins · Sean E Nork
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    ABSTRACT: Malleolar ankle fractures associated with syndesmotic injuries are common. Diagnosis of the syndesmotic injury can be difficult and often requires intraoperative fluoroscopic stress testing. Accurate reduction and stable fixation of the syndesmosis are critical to maximize patient outcomes. Recent literature has demonstrated that the unstable syndesmosis is particularly prone to iatrogenic malreduction. Multiple types of malreduction can occur, including translational, rotational, and overcompression. Knowledge of the technical details regarding intraoperative reduction methods and reduction assessment can minimize the risk of syndesmotic malreduction and improve patient outcomes. Copyright 2015 by the American Academy of Orthopaedic Surgeons.
    The Journal of the American Academy of Orthopaedic Surgeons 08/2015; 23(8):510-518. DOI:10.5435/JAAOS-D-14-00233 · 2.40 Impact Factor
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    ABSTRACT: While there is conflicting evidence regarding the importance of anatomic reduction for tibial plateau fractures, there are currently no studies that analyse our ability to grade reduction based on fluoroscopic imaging. The purpose of this study was to determine the accuracy of fluoroscopy in judging tibial plateau articular reduction. Ten embalmed human cadavers were selected. The lateral plateau was sagitally sectioned, and the joint was reduced under direct visualization. Lateral, anterior-posterior (AP), and joint line fluoroscopic views were obtained. The same fluoroscopic views were obtained with 2mm displacement and 5mm displacement. The images were randomised, and eight orthopaedic traumatologists were asked whether the plateau was reduced. Within each pair of conditions (view and displacement from 0mm to 5mm) sensitivity, specificity, and intraclass correlations (ICC) were evaluated. The AP-lateral view with 5mm displacement yielded the highest accuracy for detecting reduction at 90% (95% CI: 83-94%). For the other conditions, accuracy ranged from (37-83%). Sensitivity was highest for the reduced lateral view (79%, 95% CI: 57-91%). Specificity was highest in the AP-lateral view 98% (95% CI: 93-99%) for 5mm step-off. ICC was perfect for the AP-lateral view with 5mm displacement, but otherwise agreement ranged from poor to moderate at ICC=0.09-0.46. Finally, there was no additional benefit to including the joint-line view with the AP and lateral views. Using both AP and lateral views for 5mm displacement had the highest accuracy, specificity, and ICC. Outside of this scenario, agreement was poor to moderate and accuracy was low. Applying this clinically, direct visualization of the articular surface may be necessary to ensure malreduction less than 5mm. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Injury 07/2015; DOI:10.1016/j.injury.2015.06.043 · 2.46 Impact Factor
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    ABSTRACT: ASXL2 is an ETP family protein that interacts with PPARγ. We find that ASXL2-/- mice are insulin resistant, lipodystrophic, and fail to respond to a high-fat diet. Consistent with genetic variation at the ASXL2 locus and human bone mineral density, ASXL2-/- mice are also severely osteopetrotic because of failed osteoclast differentiation attended by normal bone formation. ASXL2 regulates the osteoclast via two distinct signaling pathways. It induces osteoclast formation in a PPARγ/c-Fos-dependent manner and is required for RANK ligand- and thiazolidinedione-induced bone resorption independent of PGC-1β. ASXL2 also promotes osteoclast mitochondrial biogenesis in a process mediated by PGC-1β but independent of c-Fos. Thus, ASXL2 is a master regulator of skeletal, lipid, and glucose homeostasis. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.
    Cell Reports 06/2015; 11(10). DOI:10.1016/j.celrep.2015.05.019 · 8.36 Impact Factor
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    ABSTRACT: Nonunion following locked bridge plating of comminuted distal femur fractures is not uncommon. "Dynamic" locked plating may create an improved mechanical environment thereby achieving higher union rates than standard locked plating constructs. Twenty-eight patients with comminuted supracondylar femur fractures treated with either dynamic or standard locked plating. Academic Level One Trauma Center INTERVENTION:: Dynamic plating was achieved using an over-drilling technique of the near cortex to allow for a 0.5 mm "halo" around the screw shaft at the near cortex. Standard locked plating was done based on manufacturer's suggested technique. The patients treated with dynamic plating were matched 1:1 with those treated with standard locked plating based on OTA classification and working length. Three blinded observers made callus measurements on six-week radiographs using a 4-point ordinal scale. The results were analyzed using a two-tailed t-test and two-way intraclass correlations. The dynamic plating group had significantly greater callus (2.0; SD, 0.7) compared to the control group (1.3: SD, 0.8, p = 0.048) with substantial agreement amongst observers in both consistency (0.724) and absolute score (0.734). With dynamic plating group, one patient failed to unite, versus three in the control group (p = 0.59). The dynamic group had a mean change in coronal plane alignment of 0.5 degrees (SD, 2.6) compared to 0.6 (SD, 3.0) for the control group (p=0.9) without fixation failure in either group. Over-drilling the near cortex in metaphyseal bridge plating can be adapted to standard implants to create a dynamic construct and increase axial motion. This technique appears to be safe and leads to increased callus formation, which may decrease nonunion rates seen with standard locked plating. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Journal of Orthopaedic Trauma 02/2015; DOI:10.1097/BOT.0000000000000315 · 1.54 Impact Factor
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    ABSTRACT: Surgeons' disagreement about ideal treatment for proximal humerus fractures (PHFs) may reflect a difference in training. We conducted a study to compare treatment decision-making by experienced shoulder and trauma fellowship--trained surgeons. Two expert shoulder surgeons and 2 expert trauma surgeons reviewed 100 consecutive PHFs surgically treated at another institution. Using available imaging, the examiners assigned scores for agreement with treatment decisions and for ratings of reduction/arthroplasty placement, fixation method, and radiographic outcomes. The scores were evaluated for interobserver reliability using intraclass correlation coefficients. Overall, these experienced surgeons agreed poorly with treatment decisions and fixation methods but agreed moderately on acceptable reductions/arthroplasty placement and final radiographic outcomes. Agreement on the final radiographic outcomes was more uniform and acceptable for both shoulder and trauma surgeons. Trauma surgeons agreed more with each other about treatment decisions than shoulder surgeons agreed with each other. In this study, surgeon disagreement and an aging population highlight the need for better evidence regarding optimal treatment for PHFs in order to improve consensus.
    American journal of orthopedics (Belle Mead, N.J.) 02/2015; 44(2):77-81.
  • Timothy B. Alton · Michael J. Gardner
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    ABSTRACT: Scapular fractures are common in polytraumatized patients and should alert treating providers to investigate for additional severe, often life-threatening injuries. While many fractures can be treated nonoperatively, surgical intervention is required if fractures are widely displaced or involve significant portions of the glenoid articular surface. The osseous anatomy of the scapula is complicated and thin, which dictates fixation options. Many classifications exist for scapular fractures and, while the AO/OTA recently contributed the New International Classification for Scapular Fractures, surgical indications remain loosely defined. Advanced imaging, such as three-dimensional CT scans, help in the diagnosis and surgical planning. The glenoid and scapular neck can be approached anterior, via the deltopectoral interval, while the posterior scapula is accessed through the modified Judet approach.
    Current Orthopaedic Practice 01/2015; 26(2):99-104. DOI:10.1097/BCO.0000000000000206
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    ABSTRACT: There is increasing evidence associating "atypical" femoral fractures with prolonged exposure to bisphosphonate therapy. The cause of these fractures is unknown and likely multifactorial. This study evaluated the hypothesis that patients with primary osteoporosis who sustain atypical femoral fracture(s) while on chronic bisphosphonate therapy have a more varus proximal femoral geometry than patients who use bisphosphonates for primary osteoporosis but do not sustain a femoral fracture. The femoral neck-shaft angle was measured on the radiographs of 111 patients with atypical femoral shaft fracture(s) and thirty-three asymptomatic patients; both groups were on chronic bisphosphonate therapy. Patients with characteristic lateral cortical thickening, stress lines, and thigh pain were included in the fracture group. The mean neck-shaft angle of the patients who sustained atypical femoral fracture(s) while taking bisphosphonates (case group) differed significantly from that of the patients on bisphosphonate therapy without a fracture (129.5° versus 133.8°; p < 0.001). Fifty-three (48%) of the patients in the case group had a neck-shaft angle that was lower than the lowest angle in the control group (128°). Side-to-side comparison in patients with a unilateral pathologic involvement and an asymptomatic contralateral lower limb did not demonstrate any significant difference between the neck-shaft angles in the two limbs. Patients on chronic bisphosphonate therapy who presented with atypical femoral fracture(s) had more varus proximal femoral geometry than those who took bisphosphonates without sustaining a fracture. Although no causative effect can be determined, a finding of varus geometry may help to better identify patients at risk for fracture after long-term bisphosphonate use. 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 11/2014; 96(22):1905-9. DOI:10.2106/JBJS.N.00075 · 4.31 Impact Factor
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    ABSTRACT: The purpose of this study was to determine factors, including day of week of hospital admission, associated with delay to surgery (DTS) and increased length of stay (LOS) in patients with hip fractures.
    Journal of Orthopaedic Trauma 09/2014; 29(3). DOI:10.1097/BOT.0000000000000221 · 1.54 Impact Factor
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    ABSTRACT: Objectives: Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures. Methods: Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit. Results: Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 218 (range 5-308) to 1138 flexion (range 90-1308). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits. Conclusions: TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.
    Injury 08/2014; 45(11). DOI:10.1016/j.injury.2014.07.017 · 2.46 Impact Factor
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    ABSTRACT: 1) Determine if distal femoral traction pins result in knee dysfunction in femoral or pelvic fracture patients, and 2) to determine if skeletal traction relieves pain more effectively than splinting for femoral shaft fractures.
    Journal of Orthopaedic Trauma 07/2014; 29(2). DOI:10.1097/BOT.0000000000000202 · 1.54 Impact Factor
  • Scott P Kaiser · Michael J Gardner · Joseph Liu · M L Chip Routt · Saam Morshed
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    ABSTRACT: Upper sacral segment dysplasia increases the risk of cortical perforation during iliosacral screw insertion. Dysmorphic sacra have narrow and angled upper osseous corridors. However, there is no validated definition of this anatomic variation. We hypothesized that pelves could be quantitatively grouped by anatomic measurements.METHODS: One hundred and four computed tomography (CT) scans and virtual outlet views of uninjured pelves were analyzed for the presence of the five qualitative characteristics of upper sacral segment dysplasia. CT scans were reformatted to measure the cross-sectional area, angulation, and length of the osseous corridor. Principal components analysis was used to identify multivariable explanations of anatomic variability, and discriminant analysis was used to assess how well such combinations can classify dysmorphic pelves.RESULTS: The prevalences of the five radiographic qualitative characteristics of upper sacral segment dysplasia, as determined by two reviewers, ranged from 28% to 53% in the cohort. The rates of agreement between the two reviewers ranged from 70% to 81%, and kappa coefficients ranged from 0.26 to 0.59. Cluster analysis revealed three pelvic phenotypes based on the maximal length of the osseous corridor in the upper two sacral segments. Forty-one percent of the pelves fell into the dysmorphic cluster. The five radiographic qualitative characteristics of dysmorphism were significantly more frequent (p < 0.007) in this cluster. A combination of upper sacral coronal and axial angulation effectively explained the variance in the data, and an inverse linear relationship between these angles and a long upper sacral segment corridor was identified. A sacral dysmorphism score was derived with the equation: (first sacral coronal angle) + 2(first sacral axial angle). An increase in the sacral dysmorphism score correlated with a lower likelihood of a safe transsacral first sacral corridor. No subjects with a sacral dysmorphism score >70 had a safe transsacral first sacral corridor.CONCLUSIONS: Sacral dysmorphism was found in 41% of the pelves. The major determinants of sacral dysmorphism are upper sacral segment coronal and axial angulation. The sacral dysmorphism score quantifies dysmorphism and can be used in preoperative planning of iliosacral screw placement.
    The Journal of Bone and Joint Surgery 07/2014; 96(14):e120. DOI:10.2106/JBJS.M.00895 · 4.31 Impact Factor
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    ABSTRACT: The null hypothesis of the current study states that routine axial CT images are obtained at a consistent and reproducible orientation relative to the sacrum. The secondary null hypothesis states that there is no difference in the measurement of the safe zone for placement of iliosacral screws when using routine axial CT images and standardized reconstructions in defined planes perpendicular and parallel to the sacrum. Retrospective review. University Level-1 Trauma Center PATIENTS:: Sixty-eight consecutive trauma patients evaluated with routine pelvic computed tomography, without pelvic ring injury. Retrospective radiographic review and measurement. Sixty-eight consecutive adult patients with routine axial pelvic CT scans, without injury to the pelvic ring and obtained as part of a trauma evaluation were retrospectively identified. The orientation of the axial slices relative to the sacrum was measured for each patient and compared. The maximal cross-sectional distance at the smallest section of the sacral ala (safe zone) was measured using the routine axial CT images and these measurements compared to similar measurements taken on standardized images perpendicular (CT Inlet) and parallel (CT Outlet) to the body of the sacrum. Additional data referencing the orientation of multiple sacral radiographic landmarks were also collected. The orientation of routine axial CT image planes relative to the sacrum spanned a wide range. The angle between the routine axial CT plane and the sacrum varied from 43.5 degrees to 82.0 degrees (SD = 9 degrees). Significant differences were found in measured safe zones of routine axial CT images compared to standardized CT Inlet and CT Outlet images. Compared to CT Inlet images, routine axial CT images underestimated safe zones for transverse sacral screws at both S1 (p<0.01) and S2 (p<0.01). When compared to CT Outlet images, routine axial CT images overestimated safe zones for oblique sacro-iliac screws (p<0.01), and underestimated the safe zone for S2 transverse sacral style screws (p<0.01). No significant differences in measured variables were found between genders and sacral morphology. Our null hypotheses were rejected: routine axial CT images were found to be at widely ranging orientations relative to the sacrum, and standardized CT images (CT Inlet and CT Outlet) demonstrated statistically significant differences in measurements of safe zones compared to routine axial CT images. Furthermore, the CT Inlet and CT Outlet views provide additional information regarding sacral landmarks that could be useful for pre-operative planning.
    Journal of orthopaedic trauma 04/2014; DOI:10.1097/BOT.0000000000000127 · 1.54 Impact Factor
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    ABSTRACT: To determine if clavicle fracture displacement and shortening are different between upright and supine radiographic examinations. Combined retrospective and prospective comparative study. Level I Trauma Center PATIENTS:: Forty-six patients (mean age 49 years, range 24-89 years) with an acute clavicle fracture were evaluated. Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the two positions. One resident and three traumatologists classified the fractures and measured displacement and shortening. Data was aggregated and compared to ensure reliability with a two-way mixed intraclass correlation (ICC). Fracture displacement was significantly greater when measured from upright radiographs (15.9±8.9mm) than from supine radiographs (8.4±6.6mm, p<0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright, but not on supine radiographs. Compared to the uninjured side, 3.0±10.7mm of shortening was noted on upright radiographs and 1.3±9.5mm of lengthening on supine radiographs (p<0.001). The ICC was 0.82 (95% CI: 0.73-0.89) for OTA fracture classification, 0.81 (95% CI: 0.75-0.87) for vertical displacement, and 0.92 (95% CI: 0.88-0.95) for injured clavicle length, demonstrating very high agreement among evaluators. Increased fracture displacement and shortening was observed on upright compared to supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.
    Journal of orthopaedic trauma 04/2014; DOI:10.1097/BOT.0000000000000129 · 1.54 Impact Factor
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    ABSTRACT: The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a two-staged protocol of acute spanning external fixation and later definitive internal fixation. Retrospective comparison study. Two level I trauma centers. A total of 85 OTA type 41C bicondylar tibial plateau fractures and 97 OTA type 43C pilon fractures treated between 2005 to 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an "overlapping" group and a "non-overlapping" group. Fifty patients had overlapping pin sites and 132 did not. Presence of a deep wound infection RESULTS:: Overall, 25 patients developed a deep wound infection. Of the 50 patients in the "overlapping" group, 12 (24%) developed a deep infection, compared to 13 (10%) of the 132 patients in the "non-overlapping" group (p = 0.033). Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the two-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use.
    Journal of orthopaedic trauma 02/2014; 28(9). DOI:10.1097/BOT.0000000000000077 · 1.54 Impact Factor
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    ABSTRACT: The evolution of locking plates and modern nail constructs provides the orthopaedic trauma surgeon with a myriad of options with regard to implant selection for common fractures. There is a significant amount of biomechanical literature comparing modern constructs with those conventionally used. A basic understanding of this literature is required in order to make informed decisions with regard to implant selection in the management of these injuries. This article reviews the most recent biomechanical literature regarding implant selection and application for a variety of commonly treated injuries including fractures of the clavicle, proximal humerus, distal humerus, intertrochanteric hip region, distal femur and bicondylar tibial plateau.
    Journal of orthopaedic trauma 01/2014; DOI:10.1097/BOT.0000000000000072 · 1.54 Impact Factor
  • Steven Cherney · Michael J Gardner
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    ABSTRACT: Successful treatment of bicondylar tibial plateau requires focused and specific assessment and treatment of the medial fragment. Many fragment variations exist that help guide treatment. This may include posteromedial or medial plating using a variety of reduction and fixation techniques, or indirect reduction and lateral locked plating. With appropriate assessment, good results can be achieved.
    The journal of knee surgery 12/2013; 27(01). DOI:10.1055/s-0033-1363518
  • Michael J. Gardner
    Techniques in Orthopaedics 12/2013; 28(4):275. DOI:10.1097/BTO.0000000000000033
  • Journal of orthopaedic trauma 11/2013; 27(11):605-6. DOI:10.1097/01.bot.0000437078.28608.89 · 1.54 Impact Factor
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    ABSTRACT: OBJECTIVES:: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. DESIGN:: Retrospective review SETTING:: Three Level I or II Trauma Centers PATIENTS/PARTICIPANTS:: Three-hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17 - 97 years), 55% were female, 34% obese, 19% diabetic, and 24% smokers. INTERVENTION:: All patients were managed with open reduction internal fixation (ORIF) using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and either non-locked, locked or a combination of locked and non-locked screws in the proximal fragment. MAIN OUTCOME MEASUREMENTS:: Risk factors for re-operation to promote union, deep infection, and implant failure. RESULTS:: After the index procedure, 64 fractures (19%) required re-operation to promote union, including 30 that had a planned staged bone grafting due to metaphyseal defect after debridement of an open fracture. Independent risk factors for re-operation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. CONCLUSIONS:: The identified risk factors for re-operation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. The majority of these factors are out of surgeon control, but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure.
    Journal of orthopaedic trauma 06/2013; 28(2). DOI:10.1097/BOT.0b013e31829e6dd0 · 1.54 Impact Factor

Publication Stats

3k Citations
313.44 Total Impact Points

Institutions

  • 2009–2015
    • Washington University in St. Louis
      • Department of Orthopaedic Surgery
      San Luis, Missouri, United States
    • Illinois Bone and Joint Institute
      Chicago, Illinois, United States
  • 2011
    • Barnes Jewish Hospital
      San Luis, Missouri, United States
    • University of Pennsylvania
      • Department of Orthopaedic Surgery
      Philadelphia, PA, United States
  • 2008–2009
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2004–2009
    • Hospital for Special Surgery
      • Department of Orthopaedic Surgery
      New York City, NY, United States
  • 2007
    • University of Zurich
      • Department of Pediatric Orthopaedics
      Zürich, ZH, Switzerland
    • Hannover Medical School
      • Trauma Department
      Hannover, Lower Saxony, Germany
    • State University of New York Upstate Medical University
      Syracuse, New York, United States
  • 2006
    • Weill Cornell Medical College
      • Department of Orthopaedic Surgery
      New York City, New York, United States
  • 2002
    • New York Presbyterian Hospital
      New York City, New York, United States