pediatric orthopedics

Understanding Rotationplasty – Alternative to Limb Sparing Surgery

Rotationplasty Child Limb Sparing Surgery AlternativeRotationplasty is a surgical option for young children who have been diagnosed with a variety of malignant or benign conditions. Rotationplasty is most commonly used as a treatment option for osteosarcoma or Ewing’s sarcoma in the distal femur or proximal tibia. This procedure can also be used in the proximal femur for rotationplasty in the hip, but this is much less common than the knee.

In rotationplasty, the bone cancer and surrounding tissues are removed and the remaining lower section of the leg is rotated before reattaching to the healthy upper section.  Rotationplasty is typically recommended when a portion of the limb is injured or diseased.

During the leg rotationplasty procedure, the ankle becomes the knee joint.  A prosthesis is built that allows the foot and ankle to function as the patient’s knee.  This prosthesis is different than a typical prosthetic device since it requires consideration of an anatomical ankle to act as the knee.  The ankle (new knee) requires structural support so that the patient does not overextend the ankle.  Prosthetic fit and function are very critical and should only be performed by a skilled prosthetist.

Patients who undergo rotationplasty as a surgical option for treatment require intensive physical therapy to gain motion and strength in the reconstructed limb. A physical therapist and prosthetist who are skilled in this specific design/procedure should work very closely with the patient’s orthopedic surgeon to guide the exercise program and prosthetic fitting.

Other surgical options for young patients with sarcomas such as osteosarcoma or Ewing’s sarcoma are:

When making the decision whether to receive rotationplasty versus the other treatment options, parents should take into consideration the age of the child, the location and size of the cancer, medical diagnosis and prognosis as well as the “functional outcomes” that the parents/child/physician agree on.

Rotationplasty is a good option for young patients who have not finished growing and have a malignant bone tumor around the knee joint.  Because their legs have not grown completely, the leg length difference will not be as great.  Also, the young patient will be able to run and jump and keep up with their friends and classmates.  The patient can participate in most sports even those with jumping and high impact.  Because the ankle joint is a natural joint functioning as the “new knee,” the patient has greater control of the “knee” with sensation of how it is moving as well as the position of the knee as the patient walks and runs.

At Emory Orthopaedics & Spine, we work closely with the resources at Children’s Healthcare of Atlanta’s Aflac Cancer and Blood Disorders Center, one of the largest childhood cancer programs in the country. Our continuum of care features pediatric experts in orthopedic surgery, radiation oncology, social work, case management, physical therapy and prosthetics.

Related Resources:

About the Experts

Dr. David MonsonAbout Dr. Monson
David K. Monson, MD, assistant professor of Orthopaedic Surgery and Chief of Orthopaedic Surgery at Emory University Hospital Midtown, started practicing at Emory in 1988. Dr. Monson is an expert in the treatment of rare tumors (sarcomas of the bone and soft tissue). Dr. Monson’s specialties are Orthopaedic Surgery (Board certified since 1990) and Orthopaedic Oncology. His areas of clinical interest are orthopaedic tumors, sarcoma, and limb reconstruction.

 

Dr. Shervin OskoueiAbout Dr. Oskouei
Shervin V. Oskouei, MD, assistant professor of Orthopaedic Surgery at Emory University, is an expert in the treatment of musculoskeletal (extremity) tumors, total hip and total knee replacements and revisions. Dr. Oskouei started practicing at Emory in 2004. Dr. Oskouei is board-certified and fellowship trained in orthopaedic surgery. Combining his experience and interests with the state-of-the-art facilities of Emory University and the Winship Cancer Institute of Emory University allows Dr. Oskouei to treat patients with the latest modalities using a multi-disciplinary approach.

About Emory Orthopaedic Oncology
Dr. Monson and Dr. Oskouei lead the Emory Musculoskeletal Oncology and Limb Reconstruction program at Emory.  The world – class program treats a variety of conditions, including benign and malignant tumors of the extremities and spine, as well as metastatic disease. Together, they offer a combined 34 years of clinical practice experience. They care for both pediatric and adult aged patients.

Both of these physicians belong to the Musculoskeletal Tumor Society which requires fellowship training in orthopaedic oncology.  Physicians belonging to this group must also have a primary clinical focus in orthopaedic oncology.  This is important for patients because it means the specialist you are seeing has had extra training in this area and is viewed by peers as an expert in the care of orthopaedic oncology. Patients should take the time to research physicians in their area to determine if they are seeing an orthopaedic oncology specialist that belongs to this organization.

Get the Facts about the Orthopaedic Considerations for Children with Cerebral Palsy

Cerebral palsy (CP) is the most common motor disability during childhood. It is a life-long condition that affects the communication between the brain and the muscles and the condition can cause a variety of motor disabilities and issues. Disability resulting from cerebral palsy can be very mild, with the child appearing to be a little clumsy, to more severe, where the child may be unable to walk. Despite the difficulty with motor control/movement, many children with cerebral palsy have normal intelligence.

Common Symptoms of Cerebral Palsy include:

The signs and symptoms of cerebral palsy vary depending on the type of cerebral palsy, degree of disability, and how each child experiences these symptoms.

• Muscle weakness
• Difficulty controlling the arms or legs
• Shaking of the arms or legs (called spasticity)
• Muscle stiffness in the legs
• Clenched fists

Causes of Cerebral Palsy 
The cause of cerebral palsy is often unknown, but there are some links to premature birth, severe jaundice after birth, and an injury to the brain. If you have any concerns about your child’s development, talk to your pediatrician at your routine visit.

Unfortunately there is no cure for cerebral palsy right now. The best course of action is to manage the symptoms with a team of specialists including an orthopedic surgeon. At Emory Orthopaedics and Spine Center, when it comes to pediatric patients coping with cerebral palsy, we focus on preventing or minimizing deformities.

Orthopaedic Considerations & Risks From Cerebral Palsy:

Limb Shortening 
As a child develops, some children will develop a shortening of the leg and arm on only one side of the body. The difference between the legs can be up to two inches. If the parent notices a shortening, please contact a pediatric orthopedic surgeon who will be able to help determine the degree of difference between the legs and recommend appropriate treatment options. The surgeon may recommend a heel lift that is to be worn in the child’s shoes. A heel lift may also help prevent problems in the hip and spine. A leg length difference left untreated could eventually lead to a curvature of the spine called scoliosis.

Scoliosis
Scoliosis is a curvature of the spine and is very common in children with cerebral palsy. One in five children with CP will have scoliosis so it is very important to see a pediatric orthopaedic surgeon to help monitor it. Scoliosis is usually mild and will not need anything more than regular observation by your doctor. Occasionally scoliosis can worsen and require more extensive treatments.

At the Emory Orthopaedics and Spine Center, we typically use non-operative treatments such as modification of a wheelchair, bracing or casting to minimize the worsening of scoliosis before we consider surgical treatments. Surgery is typically reserved for more severe cases of scoliosis. Emory pediatric orthopaedists Dr. Robert Bruce, Jr. and Dr. Nicholas Fletcher have extensive experience with growing rod and Vertical Expandable Prosthetic Titanium Rib (VEPTR) for the management of severe scoliosis in young patients. These techniques allow for continued growth of the spine in younger children to allow normal development and function. Some older children may need true spinal fusion surgery in order to stop the spine from curving.

Joint Problems
In children with cerebral palsy, it is often difficult to prevent “contracture,” an extreme stiffening of the joints caused by the unequal pull of one muscle over the other. The child will usually work with his or her care team to learn how to stretch the muscles to try to help prevent the joints from stiffening. The orthopaedic surgeon may also recommend braces, casting, or medication to improve mobility in the child’s muscles and joints. Occasionally contractures may begin to cause significant problems in the joints such as an inability to straighten out the leg and stand or a hip which may slide out of the socket. These are problems best managed by a surgeon with lengthening of tendons or perhaps a joint realignment surgery.

Foot Problems
Children with cerebral palsy will often also have difficulties with their feet due to the unequal pull of one muscle over another. These can result in problems with things as basic as getting a shoe on to walking or running. Most patients can be managed with physical therapy or possibly a special brace to hold the foot in a better position. Problems that are more severe may require surgery to rebalance the muscles in the foot or realign the foot so that it functions better.

If you have additional questions about Cerebral Palsy and its implications for pediatric patients, please leave them for us in the comments below.

About the Authors

About Robert Bruce, Jr., MD
Dr. Bruce has been a fixture in the Atlanta community for 17 years having started practicing at Emory in 1995. He is the director of the Children’s Healthcare of Atlanta (CHOA) cerebral palsy program and has a tremendous experience caring for all types of orthopaedic conditions in children with cerebral palsy from the spine to the hips to the feet. Dr. Bruce is also specialty trained in Ilizarov and the treatment of leg length differences and angular deformities. Outside of his clinical duties, Dr. Bruce serves on the CHOA medical board, is the past medical director of Egleston campus, and is currently the head of the orthopaedic team at Egleston hospital.

About Nick Fletcher, MD
Dr. Fletcher has been practicing at Emory since 2010 and cares for all forms of pediatric spinal problems including adolescent scoliosis, neuromuscular scoliosis, congenital scoliosis, early onset scoliosis, kyphosis, and spondylolisthesis. 
He also has spoken locally, nationally, and internationally on his research in scoliosis. His work on adolescent scoliosis has been presented as far away as Japan and he has published multiple studies on early onset and adolescent scoliosis. He also received the 2010 T. Boone Pickens Award for Spinal research for his research in Adolescent Idiopathic Scoliosis. Dr. Fletcher is a current member of the Pediatric Orthopaedic Society of North America’s (POSNA) evidenced based medicine committee and the Children’s Healthcare of Atlanta spinal infection prevention taskforce. His current research on post operative care following spinal surgery will be presented at this year’s POSNA annual meeting in Toronto, Canada.

Dr. Fletcher also specializes in pediatric and young adult hip conditions including hip dysplasia, femoroacetabular impingement (FAI), perthes disease, avascular necrosis, and slipped capital femoral epiphysis. He is one of only a handful of surgeons in the southeast with expertise in the Ganz or periacetabular osteotomy (PAO) for hip dysplasia and the modified Dunn osteotomy for slipped capital femoral epiphysis. He takes care of children of all ages with hip conditions in addition to young adults with hip dysplasia and impingement. He also has extensive experience in hip reconstruction for children with cerebral palsy and hip conditions such as dysplasia, subluxation, or dislocation.

Does Your Child Have Hip or Spine Problems? Chat Live with Dr. Fletcher!

Pediatric Orthopedic ChatDid you know that children can be affected by a wide array of orthopaedic hip and spine issues? Scoliosis, kyphosis, hip dysplasia, leg length differences and femoroacetabular impingement are just a few of the conditions our team sees most commonly from pediatric patients. These conditions can lead to time away from school and chronic pain and disability later in life.

Join Emory Pediatric Orthopaedic surgeon, Dr. Nicholas Fletcher, for a live interactive web chat on Tuesday, February 5 at noon to get all your questions about symptoms, causes and the newest treatment options for pediatric orthopedic hip and spine conditions answered! See you there!


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About Dr. Fletcher
Dr. Nicholas FletcherDr. Fletcher takes care of all pediatric orthopaedic trauma, neuromuscular disorders, leg length differences, foot conditions, and angular deformities of the lower limbs. In addition, the management of pediatric spinal and hip conditions are particular areas of expertise. Dr. Fletcher also specializes in pediatric and young adult hip conditions including hip dysplasia, femoroacetabular impingement (FAI), perthes disease, avascular necrosis, and slipped capital femoral epiphysis. He is one of only a handful of surgeons in the southeast with expertise in the Ganz or periacetabular osteotomy (PAO) for hip dysplasia and the modified Dunn osteotomy for slipped capital femoral epiphysis. He takes care of children of all ages with hip conditions in addition to young adults with hip dysplasia and impingement.

Kids Who Play Sports are Less Likely to be Overweight as Adults

National Childhood and Obesity month (September) is just a week away. To help start building awareness around an important issue we’ll be sharing resources such as this post, to help keep your kids active and healthy.

What may be the two healthiest things kids can do today to ensure a healthier adulthood? Eat more vegetables and play sports. That’s right. Eating healthier foods, getting active, and maintaining a healthy weight when young can prevent a lifetime of weight-related problems.

According to the American College of Sports Medicine, children whose parents are overweight or obese have a greater chance of being overweight or obese themselves. Overweight children and adolescents are more likely to become obese adults – and have overweight kids themselves, continuing the cycle. Right now, more than 30% of kids in the U.S. are overweight or obese, and obesity rates among children are growing.

Youngsters who struggle with their weight are more likely to develop type 2 diabetes, heart disease, high cholesterol, hypertension, sleep apnea, and orthopedic problems when they grow up. In fact, many obese children suffer from these diseases before they ever reach adulthood.

If you have kids or work with kids, you can help reverse this trend through education and encouragement. In 2010, recognizing that our country needed to combat the obesity epidemic, First Lady Michelle Obama launched a national initiative called “Let’s Move,” with the goal of raising healthier children. In addition to teaching kids about healthy foods and making healthier choices more readily available, we can encourage them to join a sports team and get outside and play.

Whether it’s a game of catch in the neighborhood, Frisbee in the park, organized sports or bike riding with the family, including exercise in your family routine can make an enduring difference in your child’s health (and your own). They key is making exercise part of our everyday lifestyle. If we can make these differences today, our kids will grow up to be healthier adults.

Do you or your child struggle with being overweight? What changes are you making as a family to get healthier? We welcome your questions and feedback in the comments section below.

The Truth About Growing Pains

Jeffrey Webb, MDToday kids and teens are playing sports more than ever before. And they’re playing sports at a higher level, year round. It’s common to see kids playing on multiple sports teams that allow them to display their talents and ascend to the next level of competition. Naturally, kids sometimes feel pressure from coaches and parents to perform well at all these events. In short, there is no off-season for many young athletes.

What many parents may not know: an unwanted side effect of all this activity is what’s commonly referred to as “growing pains.” I often see pediatric and adolescent patients with the following symptoms: pain located near any of the joints, but most often in the front of the knees.

Although “growing pains” are common, they should not be shrugged off. In fact, these aches are not caused by simple bone growth, as many would believe. Rather, the pains are caused by repetitive stress placed on the growth plate. Growing pains are actually at the growth center where tendons meet bone. If not treated, it can cause problems for the patient, including the need to wear a brace or, in the case of foot injuries, a therapeutic boot.

Standard treatment for growing pains involves proper stretching, ice, taking anti-inflammatory drugs, and possibly rest. Sometimes, our bodies just need time to grow properly. It may also benefit a young patient to play multiple sports, instead of focusing concentrated time and energy on just football, for instance. The adolescent body is not built to perform the same movement over and over again throughout the year.

If you have an active child or teen that’s experiencing growing pains, try these treatments. If the pain persists or interferes with activities, give Emory Sports Medicine a call. With the right treatment, we can help young athletes continue with their favorite sporting activities.

Do you have any questions about childhood growing pains? If so, be sure to let me know in the comments.

About Jeffrey Webb, MD:

Jeffrey Webb, MD, is an assistant professor of orthopaedics. Dr. Webb started practicing at Emory in 2008 after completing a Fellowship in Primary Care Sports Medicine at the American Sports Medicine Institute in Birmingham, Alabama. He is board certified in pediatrics and sports medicine. He is the team physician for Decatur High School and several high schools in the Atlanta area. He also is a consulting physician for the Atlanta Dekalb International Olympic Training Center, Emory University, Oglethorpe University, Georgia Perimeter College, and the Atlanta Xplosion, women’s contact football.