Techniques and Technology Improving Outcomes for Complex Scoliosis Surgeries

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In Scoliosis Surgery, Lengthy and Complex (Albuquerque Journal), Dr. Anjali Subbaswamy (a Pediatric Intensive Care Physician at UNM) answers questions regarding a patient whose pediatrician has suggested she may need surgery and is wondering what that entails.

She notes a recent observation of markedly improved conditions post-surgery, prompting her to ask her colleague  Dr. Antony Kallur (a Pediatric Spine and Orthopedics specialist formerly with UMN and currently with New Mexico Orthopaedics) what might be contributing to the improvements:

Q: My 14-year-old daughter has scoliosis and her pediatrician thinks she might need to have surgery. What does that entail?

A: The surgical repair for scoliosis is Posterior Spinal Fusion, and it is a surgery performed often in my hospital. It is a long surgery, often taking between 6 to 8 hours. The children usually, but not always, come to the Pediatric Intensive Care Unit (PICU) afterwards for postoperative care. They might stay in the PICU for 1 to 4 days, depending on how they recover. After that, they go to our inpatient Carrie Tingley Rehabilitation Unit, where they receive physical and occupational therapy. These therapies facilitate their ability to resume their activities of daily living, and also enhance their recovery. The therapists will give you exercises to continue at home. The entire hospital stay is typically 5 to 7 days.

There are 3 different kinds of pediatric scoliosis, all of which may require surgical treatment. They are idiopathic scoliosis, neuromuscular scoliosis and congenital scoliosis. Idiopathic scoliosis is by far the most common type. This affects otherwise healthy children, who have a sideways curve in their spine, which measures greater than 10 degrees. Your pediatrician may have done the Adams Forward Bend test to assess this, followed by some X-rays.

The American Academy of Orthopedic Surgeons (AAOS) provides the following information: If the spinal curve is between 25 degrees and 45 degrees and your child is still growing, your doctor may recommend bracing. Although bracing will not straighten an existing curve, it may prevent it from getting worse to the point of requiring surgery. Your doctor may recommend surgery if your child’s curve is greater than 45-50 degrees or if bracing did not stop the curve from reaching this point. Severe curves that are not treated could eventually worsen to the point where they affect lung and heart function. That is the main medical reason for intervening.

Now, here’s some good news. I have personally noticed that the patients I get from the operating room after this procedure are in much better condition than in years past. They are more stable in terms of their breathing and blood pressure, they start eating and drinking sooner after surgery, they start sitting up and getting out of bed sooner and their pain is better controlled. It is frankly amazing to me that some of these children don’t have to come to the PICU after surgery. This surgery takes a long time and involves blood loss and many hours of anesthesia. All of those factors are stressful to the body, and these children used to come out of surgery somewhat unstable. They would require active management of their fluid balance, blood pressure, pain and breathing. We would check labs and replace electrolytes and clotting factors. Nowadays, we barely do anything except watch them closely. They typically come out of the operating room breathing on their own, with stable blood pressure and good pain control. These changes are striking improvements, and prompted me to ask my colleague Dr. Antony Kallur, “What has changed?” 

Here’s Dr. Kallur’s answer:

Well, things definitely have changed for the better in a lot of ways.

First of all we understand the importance of three dimensional correction and restoration of spinal alignment. Anesthetic techniques have changed very much and are safer with newer medications and ability to keep children unconscious but maintaining baseline nerve and brain function so that we can monitor the child’s spinal cord.

Neuro-monitoring; which is now used all the time for any scoliosis surgery has made the surgery very safe reducing the incidence of neurological injury.

The surgical techniques and our understanding of how to correct the spine and the alignment that needs to be restored has made the children able to return to all activities after healing from surgery without any restriction. The implants used are advanced to help us correct the spine and maintain alignment to healing and can be placed safely. Titanium implants used now are also biocompatible and incidence of infection is negligible in healthy children. Our incidence at Carrie Tingley hospital is ‘zero’ in healthy children.

These days, the child does not need to stay in bed or use a brace after surgery. The newer instrumentation techniques mean that need to harvest child’s own bone (from the pelvic bone) as graft for achieving fusion/healing is not needed.

The recovery from scoliosis surgery has become so much easier to the child and family compared to how it was 10 to 15 years ago. So, we achieve better correction and alignment with safer surgery with a quicker recovery and return to activities. I hope things go very smoothly for your daughter!

Anjali Subbaswamy is a Pediatric Intensive Care Physician at UNM. Antony Kallur is a Pediatric and Adult Orthopedic Surgeon and Pediatric Spine Specialist at New Mexico Orthopaedics. 

New Mexico Orthopaedics is a multi-disciplinary orthopedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300 or utilize our self-scheduling tools here.

 

Bones Are Growing Faster, Affecting Orthopedics

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Scientists say children’s skeletons are maturing sooner than they did early in the 20th century, and this could affect the timing of certain orthopedic treatments.Girls are reaching full skeletal maturity nearly 10 months earlier and boys nearly seven months earlier, according to the University of Missouri School of Medicine researchers.

“Our findings show there is a ‘new normal’ for timing when kids’ skeletons will reach full maturity,” team leader Dana Duren said in a school news release. Duren heads orthopedic research at the university’s Thompson Laboratory for Regenerative Orthopaedics.

Earlier skeletal maturity affects the timing of treatment for certain orthopedic conditions in children, such as leg-length differences and scoliosis. It may also affect use of growth hormone, the study authors said.

“The timing for the treatments of these conditions is a critical component to a good outcome,” said study co-author Mel Boeyer, a predoctoral orthopedic research fellow. “What this research shows us is physicians will need to start looking for the beginning of epiphyseal fusion sooner than they once thought.”

The researchers studied radiographs of the bones in the hands and wrists of more than 1,000 children born between 1915 and 2006. The radiographs were gathered in the Fels Longitudinal Study, a century-long study of human growth and development.

The investigators keyed in on a developmental process called epiphyseal fusion, which signals the end of the growth of the bone, Duren said.

“It begins when the growth plate, which is cartilage at the end of the bone, starts to connect the epiphysis, or bone cap, to the long bone through small calcifications. Eventually, the growth plate completely calcifies and attaches, or fuses, to the long bone. When fusion is complete, so is the growth of that bone,” Duren explained.

The researchers found that the skeletons of children born in the 1990s reached maturity faster and sooner than those of kids born in the 1930s.

The study did not look at possible causes of earlier skeletal maturity, but increased exposure to chemical compounds that resemble hormones could be a factor, the researchers said.

The findings were published recently in the journal Clinical Orthopaedics and Related Research.

 

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Bowed Legs (Blount’s Disease)

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Article Featured on AAOS

Bowed legs in a toddler is very common. When a child with bowed legs stands with his or her feet together, there is a distinct space between the lower legs and knees. This may be a result of either one, or both, of the legs curving outward. Walking often exaggerates this bowed appearance.

In most cases, bowed legs will naturally begin to straighten as the child grows. If bowed legs have not resolved by the age of 3 years, there may be an underlying cause, such as Blount’s disease or rickets.

Adolescents occasionally have bowed legs. In many of these cases, the child is significantly overweight.

Cause

Physiologic Genu Varum

In most children under 2 years old, bowing of the legs is simply a normal variation in leg appearance. Doctors refer to this type of bowing as physiologic genu varum.

In children with physiologic genu varum, the bowing begins to slowly improve at approximately 18 months of age and continues as the child grows. By ages 3 to 4, the bowing has corrected and the legs typically have a normal appearance.

Blount’s Disease

Blount’s disease is a condition that can occur in toddlers, as well as in adolescents. It results from an abnormality of the growth plate in the upper part of the shinbone (tibia). Growth plates are located at the ends of a child’s long bones. They help determine the length and shape of the adult bone.

Photo and x-ray of child with Blount's disease

(Left) Toddler with infantile Blount’s disease involving the left leg. (Right) X-ray of the left knee shows the Blount’s abnormality along the top of the shinbone. Courtesy of Texas Scottish Rite Hospital for Children

In a child under the age of 2 years, it may be impossible to distinguish infantile Blount’s disease from physiologic genu varum. By the age of 3 years, however, the bowing will worsen and an obvious problem can often be seen in an x-ray.

Rickets

Rickets is a bone disease in children that causes bowed legs and other bone deformities. Children with rickets do not get enough calcium, phosphorus, or Vitamin D — all of which are important for healthy growing bones.

Nutritional rickets is unusual in developed countries because many foods, including milk products, are fortified with Vitamin D. Rickets can also be caused by a genetic abnormality that does not allow Vitamin D to be absorbed correctly. This form of rickets may be inherited.

Symptoms

Bowed legs are most evident when a child stands and walks. The most common symptom of bowed legs is an awkward walking pattern. Toddlers with bowed legs usually have normal coordination and are not delayed in learning how to walk. The amount of bowing can be significant, however, and can be quite alarming to parents and family members.

Turning in of the feet (intoeing) is also common in toddlers and frequently occurs in combination with bowed legs.

Bowed legs do not typically cause any pain. During adolescence, however, persistent bowing can lead to discomfort in the hips, knees, and/or ankles because of the abnormal stress that the curved legs have on these joints. In addition, parents are often concerned that the child trips too frequently, particularly if intoeing is also present.

Doctor Examination

Your doctor will begin your child’s evaluation with a thorough physical examination. If your child is under age 2, in good health, and has symmetrical bowing (the same amount of bowing in both legs), then your doctor will most likely tell you that no further tests are currently needed.

However, if your doctor notes that one leg is more severely bowed than the other, he or she may recommend an x-ray of the lower legs. An x-ray of your child’s legs in the standing position can show Blount’s disease or rickets.

If your child is older than 2 1/2 at the first doctor’s visit and has symmetrical bowing, your doctor will most likely recommend an x-ray. The likelihood of your child having infantile Blount’s disease or rickets is greater at this age. If the x-ray shows signs of rickets, your doctor will order blood tests to confirm the presence of this disorder.

Treatment

Natural Progession of Disease

Physiologic genu varum nearly always spontaneously corrects itself as the child grows. This correction usually occurs by the age of 3 to 4 years.

Untreated infantile Blount’s disease or untreated rickets results in progressive worsening of the bowing in later childhood and adolescence. Ultimately, these children have leg discomfort (especially the knees) due to the abnormal stresses that occur on the joints. Adolescents with Blount’s disease are most likely to experience pain with the bowing.

An adolescent with Blount's disease

An adolescent with Blount’s disease. Courtesy of Texas Scottish Rite Hospital for Children

Nonsurgical Treatment

Physiologic genu varum. Although physiologic genu varum does not require active treatment, your doctor will want to see your child every 6 months until the bowing has resolved.

Blount’s disease. Infantile Blount’s disease does require treatment for the bowing to improve. If the disease is caught early, treatment with a brace may be all that is needed. Bracing is not effective, however, for adolescents with Blount’s disease.

Rickets. If your child has rickets, your doctor will refer you to a metabolic specialist for medical management, in addition to regular orthopaedic followup. The effects of rickets can often be controlled with medication.

Surgical Treatment

Physiologic genu varum. In rare instances, physiologic genu varum in the toddler will not completely resolve and during adolescence, the bowing may cause the child and family to have cosmetic concerns. If the deformity is severe enough, then surgery to correct the remaining bowing may be needed.

Blount’s disease. If bowing continues to progress in a child with infantile Blount’s disease despite the use of a brace, surgery will be needed by the age of 4 years. Surgery may stop further worsening and prevent permanent damage to the growth area of the shinbone.

Older children with bowed legs due to adolescent Blount’s disease require surgery to correct the problem.

Rickets. Surgery may also be needed for children with rickets whose deformities persist despite proper management with medications.

Surgical procedures. There are different procedures to correct bowed legs, and they fall into two main types.

  • Guided growth. This surgery of the growth plate stops the growth on the healthy side of the shinbone which gives the abnormal side a chance to catch up, straightening the leg with the child’s natural growth.
  • Tibial osteotomy. In this procedure, the shinbone is cut just below the knee and reshaped to correct the alignment. The bone is held in place while it heals with either an internal plate and screws, or an external frame that is positioned on the outside of the leg.

After surgery, a cast may be applied to protect the bone while it heals. Crutches may be necessary for a few weeks, and your doctor may recommend physical therapy exercises to restore strength and range of motion. Your doctor will talk to you about full recovery time and return to regular activities.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.