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Dr. Joseph Janicki: One of the pleasures and pains of the kind of research that I'm trying to do is you're going to get an answer for a very specific question. That's the awesome thing.

Scott Webb: Lurie Children's nationally ranked Division of Orthopedic Surgery and Sports Medicine is engaged in many research studies. Experts are exploring ways to improve the bone health of children, prevent injuries and the need for unnecessary surgeries and address health disparities in children's orthopedic care.

Today, we talk with three of the division specialists about their current scientific pursuits and how they will transform care for children and teens with orthopedic disorders. And joining me today are doctors Joseph Janicki, Romie Gibly, and Vineeta Swaroop.

This is Precision: Perspectives on Children's Surgery, the podcast of Lurie Children's Hospital. I'm Scott Webb. So doctors, thanks so much for your time today. We got a lot to get to. We're going to learn about your research and so much more. As we get rolling here, Dr. Janicki, tell us about the scope of your current research. And what does it entail?

Dr. Joseph Janicki: My research is really focused on multi-centered collaboratives, bringing people together with the goal of answering big questions, important questions. One of the issues with orthopedic surgery in general and pediatrics orthopedics is that a lot of the conditions we are interested in studying don't come around very often. One center might only see five or six of these injuries per year. And in order to get the kind of numbers to answer questions, if you need a hundred, that would take like 20 years to do that in one center. And so by bringing multiple people together with multiple ideas, it can be a very efficient and very powerful way to answer a question.

In addition, if you bring multiple places and people together, it really helps the generalizability of that question because it's not just one place, one center, one area as well as the acceptability of it. If one center thinks it's the greatest idea and another center isn't really involved in the process, they won't necessarily believe whatever the answer is. And so by bringing people together, we can be a much more powerful effective way of answering questions and getting much bigger effect.

And so we've created a group called IMPACCT, which stands for Infrastructure for Musculoskeletal Pediatric Acute Care Clinical Trials, so two C's in IMPACCT. And what this group is a group really focusing on infrastructure, the infrastructure of how to answer these questions and the process of answering the questions. And this is a group that started at Lurie Children's with collaborators initially in the UK as well as in Canada to bring people together. And the main people were myself, Jim Wright and Andrew Howard who are mentors of mine and then, my very important research partner, Jamie Burgess. And we've gone through a process of identifying the "important questions" in pediatrics.

The best way to answer questions is what we call a clinical trial. Clinical trials are the level one evidence. Unfortunately, clinical trials are very complicated and also often very expensive. And so you really need outside funding sources who are able to provide the funding and even some of the infrastructure to help us with this process. And so we've gone to the NIH after our process and identified a couple of questions. NIH, unfortunately, does not fund infrastructure, they fund questions. And so the two questions we're focusing on are distal radius fractures, specifically a certain kind in which they're really displaced. And then, these elbow fractures, they're called medial epicondyle fractures. And there's a lot of debate in our societies about how best to treat these. Some people will say you always need to fix these medial epicondyle and distal radius fractures, and some people will say you never need to do it, and there's people like me who are not really sure. And so what we do is we create clinical trials.

So we went through the process, got some buy in. And we went to NIH and they fortunately gave us funding to complete these studies. And so currently, the studies are about to get underway and we have 35 sites across the US and Canada in order to help us answer these things. And with that, hopefully in the end, we will have better questions to be answered. Now, the fun thing is while we're answering these questions now, all the IMPACCT consortium is is a machine, it's like a factory to create and answer these trials. So hopefully, as time goes on, we'll be able to put other important questions through this infrastructure in order to best figure out the ways to answer these questions, but also most importantly, how to best to treat our children.

Scott Webb: Yeah. Right. In the end, it's all about treating the children and, Dr. Gibly, I wanted to give you an opportunity. Tell us about your current research, who it's going to impact the most and so on.

Dr. Romie Gibly: So I come from a bit of a different background. I am an MD PhD. I did some training in biomedical engineering and a lot of my interests lie more on the basic science end. So these are things that are looking a lot further down the road in terms of having direct impact. I also have clinical projects at Lurie. One of which has led to the use of a rapid MRI program for evaluation of musculoskeletal infections in children. This has been deployed at Lurie and is starting to get shared with other institutions. It has been a real success for us, but that's the smaller end of my research.

On the larger end of my time and effort is a basic and translational science lab across the street at the Lurie Research Building. And in that lab, we are looking at two main avenues of research. These both involve stem cell work and animal studies, and we're looking at two main veins. The big one is looking at the impact of electronic cigarette vaping on the way bone heals and grows. There's been a lot of research done in the last 20, 30 years about how smoking impacts those things. But if we look at the population in general, especially in kids, smoking is not really a big problem, but the electronic cigarettes, the vaping, the e-cigs is a huge problem. Studies show that a majority of high schoolers have tried it, if not are regular users, even though it's not supposed to be. It's a huge problem right now. And we don't do a good job of screening for it and we certainly don't understand what the implications of that in our patients are. And so we're starting with some of the basics, both looking at their impact on the musculoskeletal stem cells that are responsible for bone growth and healing, as well as looking at the impact on a fracture model, so a broken bone in animals and seeing how exposure to those compounds can affect the ability to heal. And while that research is still early, we're only about a year into it, we're already seeing pretty universal negative impacts on the way bone heals, the way bone grows and the way those cells proliferate and divide, how they grow into the tissues that we need to make our bones strong.

The other half of the basic science research that I am doing over there is trying to unwind some of the fundamental questions as to why do kids heal things so much better than adults do? There are a number of injuries that are totally acceptable in a kid and will heal great. And if the same thing happened to an adult, there's no way that would work. It would be malpractice to treat it the way we do in kids, but kids can heal it wonderfully. And on a fundamental level, we don't really understand why that is. And so the last time a lot of this was looked at closely predates a lot of our understanding of what is called epigenetics. So DNA has certain instructions in terms of the proteins and things that your body makes, but there are a whole number of other signals that happen around the DNA that control how your body interprets that code and how much of X, Y, or Z it makes and when it makes it. And those epigenetic signals weren't really well understood when things like the human genome project started and they've really become better understood in the last 10 to 20 years. And so our goal is to leverage our better understanding of how epigenetics works to see if we can decipher a bit of why kids heal things so much better than adults do. And that work is definitely still in its baby phases, but those are the two main avenues there for me.

Scott Webb: Yeah, really interesting. One of the things I'm learning today, Dr. Swaroop, is research is about asking questions and then trying to answer those questions, right? So wondering what questions are you trying to answer right now and, if you get those answers, who will the answers benefit?

Dr. Vineeta Swaroop: My elective practice is mainly pediatric patients with neuromuscular disorders. And so most of my clinical research projects are about questions that are pertinent to those patients. And one that I'm most excited about right now is a multicenter randomized controlled trial that we're doing to look at pain management for patients with cerebral palsy who are undergoing hip reconstruction, which is actually a very commonly needed procedure in patients with cerebral palsy. And it is a bony procedure, and so it is a relatively big surgery and it does lead to discomfort afterwards. And so what we're looking at is enrolling patients into this trial in which they'll receive one of two options at the conclusion of the surgery before they wake up. They'll either receive an injection into the surgical site of saline, which is salt water, that's the placebo group, or they'll receive an injection of three different medications which are injected into the surgical site. The patients won't know which injection they're getting and neither will I. But our goal is to look at their pain control postoperatively, to see if the patients who receive the medications in the injection require less opioids afterwards and are just as satisfied or more satisfied with their pain management postoperatively. And this combination of three medications has been used extensively in various aspects of adult orthopedic surgery and has been shown to be safe and efficacious in decreasing the need for opioids postoperatively, but it has not been studied in pediatric patients.

And our goal is specifically in my population of patients who have neuromuscular disorders, if we can decrease the need for opioids, then we also decrease all of the risks and complications that come with using opioids like nausea, vomiting, constipation, urinary retention, confusion, respiratory depression, which are especially important in neuromuscular patients.

Scott Webb: Yeah, this is really fascinating. I love having three of you. You know, you all are sort of in the same area in the same division, but doing such different things and such different research. And staying with you, Dr. Swaroop. When we think about the study and the research that you're doing, ultimately, who's going to benefit, right? Children, families, but specifically, maybe you can just sort of connect those dots for us.

Dr. Vineeta Swaroop: Like I mentioned, this injection is used routinely in adult orthopedic surgery across a variety of different procedures, but really not much has been published at all in the literature about the safety of using these same medications in pediatric patients undergoing surgery. So while our short-term goal is to improve the pain control of patients with cerebral palsy undergoing this procedure, if we can prove that this injection is both safe and effective at decreasing the need for opioids after pediatric patients undergo this surgery, then it can be applied widely throughout pediatric orthopedic surgery and it has the potential to really make a difference.

Scott Webb: Coming back to you, Dr. Janicki, sort of the same question, you know, when you think about the research that you're doing, ultimately, if you're able to answer those questions, who really is going to benefit the most?

Dr. Joseph Janicki: One of the pleasures and pains of the kind of research that I'm trying to do is you're going to get an answer for a very specific question. That's the awesome thing. So a 12-year-old comes in with this type of elbow fracture then no one really definitely knows how to fix it for sure or whether to fix it at all, and we're going to have a good answer to that, and similar with this type of wrist fracture. The downside, of course, is that because it's so specific, it's sometimes challenging to extrapolate into other types of injuries. It's wonderful in one way, but the process hopefully can be used for other type of questions so that we can broaden the number of children that are being helped and that can benefit from this research.

Scott Webb: So Dr. Gibly, I want to bring you back here, we're talking about the different research that you're all doing and who it's going to benefit and how there are short-term benefits and maybe long-term benefits and ramifications. So I wanted to ask you, how'd you get into this specialty or your clinical interests, your research interests? Like what brought you here? I always find that the journey from medical school to where folks end up is often an interesting one, and maybe you can share yours.

Dr. Romie Gibly: I would say it is probably not the most traditional like, "Ooh, I always wanted to be an orthopedic surgeon." I was mostly just a pretty big nerd as a high schooler. I'm first generation and our family had to do a lot of fixing and building to get things that we needed. And so I've always done a lot of tool using. And in college, I was drawn to research. I originally thought I was going to be an industrial chemist. And I had a friend talk me into considering an MD PhD program, which is a combined medical scientist training program sponsored by the NIH. I ended up doing that at Northwestern. And during that time, I found the lab that I did my PhD in. Our studies there worked with a bunch of different specialties. So we worked with engineers, chemists, biologists, endocrinologists, and transplant surgeons. And I really found the nexus of all those specialties and working across those specialties to be really exciting and interesting, and that really colored a lot of what I wanted to do with my life in terms of research just from a conceptual framework.

And then once I really got to start doing clinical medicine in medical school, the tool use and the fixing and the rewards of being able to fix things like that really made orthopedics an obvious answer. And within orthopedics, it's just really hard to have a bad day when you're taking care of kids all day. And I found my way into pediatric orthopedics that way, and I've been very happy there. And the research is really focused on trying to answer some basic questions while understanding that, to answer some of those questions, we really need to leverage the skill sets of a lot of different specialties.

Scott Webb: Yeah, that's awesome. Yeah, I've have the pleasure of doing these, hosting these. And I find with the Lurie experts that I get on that it doesn't sound like you folks have bad days very often, that when you're working with children and families and trying to answer these questions and help children and families live happy, healthy, normal lives, it's hard to have a bad day. And Dr. Swaroop, I'm wondering about your training. You know, how'd you get where you are today, so how'd you choose the specialty, your research interest. Tell us a little bit about your background.

Dr. Vineeta Swaroop: I went into medical to become an orthopedic surgeon. I knew from the beginning that's what I wanted to do. Like many people, that's because of a personal experience that I had, where when I was actually a freshman in high school, I had spine surgery at what was then Children's Memorial Hospital. And I told my surgeon who was then the chair of the Department of Orthopedics at Northwestern, I told him I was going to come work for him one day. And he said, "Sure, sweetheart." And then, I showed up in there. I'm stubborn enough that I made that happen. But he was a huge mentor in my life. And he actually then, while I was a resident, helped me realize that pediatrics was where I wanted to be as well. And I knew I wanted to do orthopedics. I found pediatrics during residency, and then I had another wonderful mentor at Children's, Dr. Diaz, whose specialty was neuromuscular. And he really guided me and introduced the field to me. And that kind of shaped what I focused on in my fellowship so that I could come back and work together with him on patients with neuromuscular disorders. And he has since retired, but it was an honor that I got to work side by side with him and learn from everything that he had learned over his 40-year career, taking care of patients with spina bifida and cerebral palsy and other neuromuscular conditions.

Scott Webb: That's such an awesome story. Dr. Janicki, you know, I know that you are an expert in your field, but I'm sure that sometimes you have questions. So maybe you can share with listeners, who do you turn to? Whether it's mentors, people who helped you along the way, or colleagues there in the office or from around the country, who do you turn to when you have questions?

Dr. Joseph Janicki: Sort of all the above. A place like Lurie with 13 other pediatric orthopedic surgeons, I always get different ideas and different ways to approach a problem. One of the things that many of us go into pediatric orthopedics for is because, yes, we're dealing with children, but from the intellectual standpoint, a lot of the questions and how to treat them are pretty big. One of my favorite times was a conference when I was in training on Friday mornings in which two of my initial mentors, George Thompson and Dan Cooperman, would be debating these problems in pediatric orthopedics. And they were literally ying and yang. George was fairly proactive and Dan was more of a wait-and-see guy, and that really got me interested.

Currently, you know, I go to my partners for ideas, my senior partners, my contemporaries, as well as my junior partners. Romie has come up with lot of good ideas and even residents. I was having a tricky case this last week, and one of my residents came with an idea that I think was really key to improving this child's outcome. And then, in the much more global sense, I have great mentors across the country and literally around the world, in Canada, in the UK, Switzerland who I can call and text and say, "Hey, what would you do with this?" or "With this research issue, we're having trouble getting families to agree to this, what do you do that's been successful?" One of the things I love about pediatric orthopedics, it's really a collaborative field both locally, but also literally worldwide in which when you're focusing on the children and try to figure out how to treat children in the best way, it really breaks down a lot of the barriers, shall we say, competition, that may exist in other adult fields.

Scott Webb: Yeah. So I was talking to another Lurie expert recently, and they were saying, Dr. Swaroop, that, you know, it's really about getting doctors and clinicians and everybody out of their silos and getting them talking to each other and working with each other and trying to figure out which questions to ask and answer those questions and ultimately help children. So for you, from your perspective, who do you turn to when you have questions?

Dr. Vineeta Swaroop: So I'm going to answer this two separate ways, because I think it's at least for me two separate questions. So in terms of getting people out of their silos and collaborating and working together, which I think is so critically important, especially for instance, we have a very large spina bifida clinic at Lurie Children's. And we, I think, collaborate very effectively in this clinic. And so it's orthopedic surgery, urology, neurosurgery, pediatrics, physical medicine and rehabilitation amongst many other specialties, physical therapy, orthotics, psychology, all who are working together to provide the best possible care for these patients with a very complex condition, which while there are definite orthopedic manifestations, we have to understand all the other parts of it in order to effectively treat that part and really focus on what's going to improve each individual patient's function. So if we just focus on the orthopedic deformity, we may not end up with the best result for that patient because it is such a complex disease.

So I think that we have some really great multidisciplinary clinics at Lurie, where we really try to keep our goal and focus on what is the best overall outcome for each individual patient. And I really enjoy being a part of that. I think it's really dynamic and helps me learn more and think about other aspects of what patients are going through that I wouldn't have thought of if I only focused on my orthopedic part of it.

And then, in terms of who do I go to when I have a question, I think very similar to what Dr. Janicki said, all of those things. And then also, I think we're very lucky at Lurie that I have another partner who also specializes in neuromuscular conditions. And she and I on at least two different days of every week are constantly bouncing cases off of each other. And it's so helpful to talk it out with someone who understands the same nuances and it either solidifies the plan I already had as being the right plan, or it sometimes makes me think of doing something a little bit differently that might actually work out better. So I think that's an invaluable resource to have as well.

Scott Webb: Dr. Janicki, I know you've been around a long time and you're an expert in your field. But when you think about the next five or 10 years, what gives you hope? What's your level of optimism for the evolution of the work that you're doing?

Dr. Joseph Janicki: One of my strengths as well as weaknesses is that I'm often looking forward and always onto the next thing. And so, I'm really working personally to try to enjoy the moment and celebrate small victories that do happen, you know, like getting the the very big grant that we got and getting the study off the ground, which will happen soon, and then really celebrating the people that have helped me through that process and then, at the same time, looking forward the future. The work that I'm doing, it really leads toward future research and identifying the next questions and how to use what we have in order to answer these questions the best way we can.

It's a unique opportunity within the field to bring all these people together with minimal, shall we say, barriers so that things can get done. And so while continue to work on completing these studies, I hope to start the process again and find next set of studies and then two or three years after that, the next set of studies, so having a bunch of studies going on at the same time, having the main coordinating center at Lurie children's, so that we can help everybody get this along. But at the same time, remembering this quote, Harry S. Truman said, "You can accomplish anything in life provided that you do not mind who gets credit." And that's one of the things that I really think about. Yes, I get a lot of credits and a lot of things and again, these type of shows. At the same time, I am such a small piece of this. And my team is actually meeting right now without me and can do that so that the stuff does get done. And so I'm excited to do that.

I'm also really excited for the future of our department, having young investigators who are going to hopefully continue to bring the field forward from research, as well as from the clinical standpoint. We have three or four new ones, Dr. Gibly included who's recently come on, Dr. Niraj Patel, Dr. Brett Lullo; you know, I can't include Vineeta anymore, she's like my contemporary, who are coming on and hopefully they're going to be pushing Lurie as well as the entire field of the pediatric orthopedics forward.

Scott Webb: Yeah. You mentioned funding in there and I'm sure there were a lot of high fives and let's hope that over the years, the coming years, there's even more. Dr. Gibly, when we think about the next five years, 10 years down the road, right? I know you're fairly early on in your work and your research and your career, where do you see things going both in your area and just orthopedics in general when you look into your crystal ball?

Dr. Romie Gibly: Well, what I would say is from the orthopedics in general in a clinical sense, you probably got a bit of this from Jay, but big part of what we're realizing is just how much more powerful we are when we work together as centers across the country or across the world. So like our rapid MRI project that we're doing here at Lurie, it's all well and good for Lurie. But the real benefit is seen when things like these can be expanded to other centers and across the country. And so we started that process, I've had meetings with a couple other centers who are looking at starting a similar program that, in a lot of ways, that's similar to the multicenter trials that Jay is doing. The real power of the research I think we'll see in the next five, 10 years is trying to get it to be not piecemeal at individual places, but really broader acceptance.

In terms of my own basic science research, the translational stuff, I think one of the most challenging things for most regular non-research people as well as research people is the fact that basic science research is really slow, like the recent anecdote of how fast we got a COVID vaccine available is really astronomically fast on the scale of science. You know, if you ask me to say, "What do I see in five years?" I hope to say, we can say definitively what kind of impacts vaping has on bone healing. We may not have treatments for that other than to say not to vape, but that may also open up other avenues. We say, "Oh, there's a signal here that causes a negative impact." Can we harness that signal to either improve healing in other situations or mitigate the impact of that vaping?

From the other work that I'm doing with the epigenetics, that is a long-term project. That's a 20-year project, really if I'm being honest. And the end goal is saying we can identify factors that are important to the reasons why children heal faster and can those then be extrapolated into therapies or techniques to help difficult fractures heal better or to help adults who don't heal so well have them heal better.

And that may be hard, I think for a lot of people to hear when they think about research. But unfortunately, the pace of science is much, much slower. The amount of repetitions you need to have and then a number of troubleshooting that has to go through, it can be very simple to say, "Let's look for the signal on this protein's output." And that series of experiments can take you a year to figure out. And that's even just a tiny little piece of the overall picture. And so while that tries people's patience, I'm still very hopeful. That's how we get to places where we have the technologies to have something like the COVID vaccine, right? No one sat down with a cocktail napkin a year ago and a year later had a COVID vaccine, right? There's decades and decades of work that went into having the material and the knowledge and the understandings that made that doable.

So we're really working on some of that fundamental knowledge, acknowledging that the actual output from that may take quite a while to see. But hopefully, you check back in with me in five years and hopefully I've got some really great and interesting avenues that we are then mechanistically exploring to see how they can be turned around to actually have an impact.

Scott Webb: Yeah, it's interesting, just listening to you all today and thinking, "Okay, so this is more of a short-term thing, one in which they maybe expect to have answers within a couple of years or five years." But how do you sort of prepare yourself when you think, "Okay, I need to answer these questions. The world needs these questions answered, but it's going to take us 10, 15, 20 years"? How do you sort of muster the stamina and prepare, roll up your sleeve and say, "Okay, we're doing this. I may not have these answers for 20 years, but I'm going to get them." How do you do that? How do you prepare yourself.

Dr. Romie Gibly: There's definitely frustrating days, especially when things aren't working the way you hope they would. But, you know, there are little milestones throughout the way that show that you're making progress. I think having a diversity of projects, having a diversity of career here. So I've got projects that are answerable in the short term. And I have patients that I see and fix on a daily and weekly basis. So I have a lot of things that give me a lot of energy and a lot of hope that I see every week and I've got some longer term projects, but I would say it's probably like raising kids. There's a lot of hiccups along the way, and you don't really get to see what happens for 20 years, but you got your frustrating days and you got your amazing days and it's a process. I think just understanding that going into it's really important. And there are also so many joys along the way, right? That's the thing, is recognizing that just because the end product is far away, it doesn't mean there isn't a lot of progress on a daily basis.

Scott Webb: And Dr. Swaroop, I'm going to give you kind of the last word here a little bit. What gives you hope for children with orthopedic conditions?

Dr. Vineeta Swaroop: There are a lot of things that give me hope. The two main ones are as I've come up in practice, it's been really nice to see that particularly for patients with neuromuscular disorders, there's really been a shift in focusing on function of each individual patient. And what can we, as healthcare professionals, do to set a realistic goal for each patient and make sure that they achieve them. And that happens in kind of the smaller level at one institution, but also by collaborating with like-minded professionals across the country who feel the same way. And I've gotten to experience that and have grown from that. And I think my patients have benefited from that too. And I see that only continuing more in the future.

Then, the other thing that gives me hope is seeing the families and their complete dedication to their children and tireless advocacy efforts to improve, funding for research and equipment and accommodation in schools, participation in adaptive sports and to watch what these families are willing to do or figure out how to do or think of to do to better the lives of their children is really inspiring. And if I can play a small role in helping with that, that would be a win for me.

Scott Webb: Yeah. A win really for you, for everybody. And you're so right. And we just as we finish up here today, you know, we think about the children, we think about all of you, the experts, the research, everything that's going on really. But in the end, it's always about those families, right? It's about those families who walk through the door at Lurie, needing you, counting on you. And then as you say, their advocacy, saying, "You wouldn't believe what they did for my child, what they did for our family. So please give them the money they need to ask more questions and get those answers that future families and children will need." So, this has been great to learn more about all of you, your research, the future, and so on. Thank you all, and you all stay well.

Dr. Joseph Janicki: Yeah, thank you so much.

Dr. Vineeta Swaroop: Thank you.

Dr. Romie Gibly: Thank you so much.

Scott Webb: And visit luriechildrens.org/ortho for more information or to make an appointment. And if you found this podcast helpful, please share on your social channels and check out the full podcast library for additional topics of interest.

This is Precision: Perspectives on Children's Surgery, the podcast from Lurie Children's Hospital. I'm Scott Webb. Stay well.