Erasing the Worry

Twenty-two-year-old Christine Schueler spent the better part of the fall on her feet—working as an attractions host intern at Walt Disney World in Orlando, welcoming children and their families to Aladdin’s Magic Carpet Ride and the Enchanted Tiki Room. It’s a job that wouldn’t have been possible a few years ago.

The recent nursing school graduate had planned to be a professional ballet dancer before hip pain from acquired hip dysplasia got in her way.

“I saw seven doctors before Dr. (Jonathan) Schoenecker when I was 17. He looked at a kidney X-ray from when I was 13 and realized that I was missing part of my pelvis. My hips had never fully formed,” the Franklin, Tennessee, native said.

Jonathan Schoenecker, M.D., Ph.D., a Vanderbilt pediatric orthopaedic surgeon performed two hip preservation surgeries on Christine; the first during the summer between her freshman and sophomore years in college, in 2012; and the second, a year later.

Schoenecker is one of many reasons the Pediatric Orthopaedics team at Monroe Carell Jr. Children’s Hospital at Vanderbilt is No. 12 in U.S. News and World Report’s Best Children’s Hospitals 2015-2016 rankings. Other reasons include the care of the pediatric orthopaedic trauma patients and the department’s trailblazing surgery in the care of young patients with scoliosis.

From broken bones to the most complex orthopaedic conditions, the team provides children and young adults like Christine with the region’s most advanced care and management of complex fractures, sports injuries, congenital bone deformities, hip and foot deformities and osteomyelitis.

Children who have orthopaedic conditions often need treatment from multiple disciplines and specialties at Children’s Hospital, which requires teamwork, coordination and comprehensive care from many types of pediatric specialists such as Genetics, Neurology, General Pediatrics, Sports Medicine, Rheumatology, Oncology, among others.

“It’s not so much that the adult doctor down the street can’t take care of kids’ orthopaedic issues,” said Gregory Mencio, M.D., Neil E. Green Professor of Pediatric Orthopaedics and chair of the department. “It’s just that most don’t do it on a regular basis. Some hospitals may do elective pediatric orthopaedic procedures or take care of fractures in kids, but they don’t necessarily have exposure to the full spectrum of problems that we see on a regular basis nor care for the volume and variety of fractures that we see in children as a result of being part of a Level 1 trauma center.”

Because children’s bones are still growing, treatments for young patients often vary from therapies for an adult suffering from a similar orthopaedic problem.

“As a parent, I want someone experienced in pediatric orthopaedics, someone who does it on a daily basis, like my partners and our team, taking care of my child’s musculoskeletal problem,” Mencio said.

 

Preservation or Replacement?

Schoenecker spends much of his time in the operating room doing hip preservation in children and adolescents— “reconstructing what they have to make it last longer,” but he smiles when describing his equally important role in the lives of his young patients and their families—erasing the worry.

“When we sit down with parents, we take away fear. If you think about it, there’s nothing that scares a parent more than something happening to their child. Nothing. That’s why I love pediatric orthopaedics. My entire job is to make it so Mom and Dad don’t wake up at 2 in the morning worrying about their child,” said Schoenecker.

“When the parents of my patients come in with their child who can’t participate in a sport; who might be having a hard time sitting; who might be in a lot of pain, we can say to them, ‘we’re going to give your child’s life back. Either by preservation or replacement, we’re going to be able to get them moving again.’”

Hip replacement, or total joint arthroplasty, is generally reserved for the older population. “You have a gap of time, from early teens to the fifth decade, where people might have hip issues and need treatment, but are not ready for total joint replacement. Our hip preservation program fills the gap,” Schoenecker said.

The bones of the hip are the femur (thighbone) and the pelvis. One of the body’s largest weight-bearing joints, the hip is where the thigh bone meets the pelvis to form a ball-and-socket joint. The hip joint consists of two main parts—the femoral head, a ball-shaped piece of bone located at the top of the thigh bone, and the acetabulum, a socket in the pelvis into which the femoral head fits. Bands of tissue, called ligaments, connect the ball to the socket and stabilize the hip.

In the dysplastic hip, like Christine Schueler’s, the acetabulum is more dish shaped and because of the inadequate coverage of the femoral head, the weight across the hip is distributed on a small surface area which results in an excessive load on the hip socket. Over time this can lead to degeneration, limitation in activity and pain.

“My acetabulum only covered (the femoral head) halfway,” Christine said. “I was standing on muscle and tendons instead of bone.”

The surgery Christine had is called PAO, which stands for periacetabular (around the acetabulum) osteotomy (cutting bone). Schoenecker cut the bone around the acetabulum and repositioned her hip socket. Her acetabulum was fixed into position with three screws.

The first surgery on her right hip took seven hours and the second, on her left hip, five hours. After five days in the hospital and five weeks of no weight bearing and four weeks on crutches, she graduated to physical therapy three days a week.

“Before the surgery, if I stood or walked for 30 minutes, I had to sit down. Now I can work a 12-hour shift in the hospital or a day at Disney with no problem. It was definitely life changing,” she said. “My hip problems changed my career path. I wanted to be a professional dancer, but I lost a lot of flexibility. Now pediatric nursing is what I really want to do,” she said, adding that she hopes to one day work at Children’s Hospital.

Schoenecker said that many people are surprised to find that hip issues are being corrected in children—it’s usually thought of as a malady of older adults.

“You don’t usually think about hip preservation as a pediatric issue, but it’s completely a pediatric issue,” Schoenecker said, adding that arthritis of the hip is usually the result of the hip being out of alignment in development.

And for reasons that are unknown, developmental hip issues in men and women differ—hip sockets in men tend to be overcovered, and undercovered in women.

“You only have a certain number of cycles that your hip is going to move, like you only have a certain amount of times that your car tire is going to turn before the rubber wears off. During development, if your hip is not made perfectly you have a very significantly fewer number of times to move your hip, be it sitting, standing, walking or running, before it wears out,” he said.

“There’s no use in realigning the car if there’s not enough rubber left,” Schoenecker says, comparing the rubber in the tire to cartilage in the joint. “With kids, there’s usually enough rubber left, so in hip preservation we go in and realign the tires so they last a lot longer.”

Schoenecker said the hardest part is knowing when to do preservation versus replacement. “In severe cases we can’t tell families that we’re positive this is going to make your child’s hip last 30-40 years, but in the less severe cases we do have that data.”

Making that decision is easier thanks to a unique collaboration at Vanderbilt—the marriage of pediatric hip preservation and the adult hip reconstruction. Once a month Schoenecker and Greg Polkowski, M.D., assistant professor of Orthopaedics and Rehabilitation, jointly see patients in clinic and operate together twice a week. The collaboration keeps patients from being bounced back and forth between doctors who do hip preservation and those who don’t.

In the past, decisions were made on hip replacement or preservation based on the age of the patient, Schoenecker said. “Pediatric orthopaedic surgeons took care of the patient up to age 18; then sports medicine docs, from 18 to 40, and then the total joint surgeon takes over at 40 and beyond. The fact is, timing of all these conditions doesn’t follow chronological age like that,” he said.

“You want a hip specialist that covers the entire spectrum, where every aspect of your child’s hip problem is looked at with the right eyes. We look at one patient in two different ways. I look at it in regards to development. My basic research is in development and regeneration,” Schoenecker said. “Dr. Polkowski also wants to preserve, but he also has tremendous knowledge about when a total joint is better than preservation. Most orthopaedic surgeons who do preservation don’t do total joints. With Greg (Polkowski) and myself, the whole spectrum is covered. The care we can provide is unbelievably comprehensive and truly pioneering. Patients don’t need to go anywhere else.”

 

Monkey bars, jungle gyms, trampolines

At Children’s Hospital about 40 percent of the pediatric orthopaedist’s time is spent repairing fractures.

“Monkey bars, jungle gyms and trampolines—those are the big three,” said Steven Lovejoy, M.D., assistant professor of Orthopaedic Surgery and Rehabilitation, referring to the causes of many of the orthopaedic traumas that they see.

Elbow fractures are the most common fracture seen at Children’s, difficult to repair because of the vasculature and growth plates around the elbow and the ligaments that hold everything together. And for femur fractures, where at some hospitals surgery is the only option offered, Vanderbilt still uses casting in many cases. “It’s kind of a lost art in the rest of the world,” Lovejoy said.

Pediatric Orthopaedics is also a member of the trauma team for Children’s Hospital’s Level 1 trauma center, designated by the American College of Surgeons (ACS).

When children come in with multiple injuries—these are commonly motor vehicle and ATV injuries—they are seen by a multidisciplinary pediatric trauma team. Once the child is stabilized, each specialty does its part.

On Memorial Day weekend of 2015, Myiah Whitley, 16, of Goodlettsville, Tennessee, was a passenger in a 1967 Mustang with no airbags and only lap belts. The car hydroplaned and wrecked just minutes after a friend had picked her up at home. Her left arm was broken in two places, and she had a collapsed lung and wrist, rib and pelvic injuries as well. Lovejoy repaired her badly broken arm with a plate and six screws.

Her mother, Tracey, said the phone call that came shortly after Myiah left the house was the call that parents dread. “I just knew,” Tracey said.

After a summer of healing and physical therapy, Myiah is back to normal and has resumed cheerleading at Merrol Hyde Magnet School in Goodlettsville.

“I was in a cast from the elbow down for about three months, but I’ve got all my muscle tone back and movement is normal. It was hard, but I’m glad it wasn’t worse,” she said.

Lovejoy said repairing bone injuries in children can be tricky because of the growth plates—the area of growing tissue near the ends of the bones in children and adolescents. Each long bone has at least two growth plates—one at each end—and the plates determine the future length and shape of the mature bone. When growth is complete, sometime during adolescence, the growth plates close and are replaced by solid bone.

“Bones grow from the ends through growth plates so we’re constantly dealing with trying to keep bones growing where the growth plates are injured with fractures,” Lovejoy said.

Special techniques for repairing bones around the growth plates are needed—including screws, nails and pins. The metals used today have improved from the past, he said.

Pediatric orthopaedists also know what fractures should be left alone to heal. “A lot of fractures in kids heal with a whole bunch of bone, and they’ll remodel.”

But he said he’s noticed a troubling trend in childhood orthopaedic injuries—many parents are less accepting of any sort of imperfection in their children. “We see wrist fractures that would heal fine if we do nothing, but it may look funny for a while because it takes about a year to remodel, and parents often want it surgically repaired. Sometimes it’s hard to convince parents to wait.”

Correcting the curve

Scoliois, or a lateral (toward the side) curvature of the spine, is another condition that keeps Vanderbilt pediatric orthopaedic surgeons busy.

Approximately 3 percent of adolescents will develop scoliosis. Many curves are small, never requiring treatment and only needing observation; however patients with curves that reach the range of 20 to 30 degrees may benefit from bracing to prevent further progression. Bracing is considered if the bones are still maturing and if they have substantial growth remaining. Surgery to correct scoliosis is generally considered when the curvature has progressed beyond 50 degrees, because curves that reach this size tend to gradually progress even when the patient has stopped growing. In the adolescent patient with severe scoliosis, fusion of the deformed section of the spine can be safely performed because there is not substantial remaining growth of the spine and chest. The spine fusion can prevent progression of the scoliosis and correct the deformity.

“Children with early onset scoliosis create challenges because they still need to grow,” said Jeff Martus, M.D., assistant professor of Orthopaedic Surgery and Rehabilitation. “When they develop scoliosis at an early age and their chest is small, you don’t want to do spine fusion because it will not allow their chest and lungs to grow to an adequate size for an adult. In addition, these patients with early-onset scoliosis commonly have other medical problems, and at Children’s we are fortunate to have excellent pediatric subspecialists to assist with overall care.”

So for these younger patients with progressive scoliosis, physicians try to delay surgery with either bracing or specialized spine casting. But if the curvature continues to worsen, surgery to implant metal “growing rods” is necessary to control the deformity but still allow for spine and chest growth. The rods are implanted and then a minor surgery is performed every 6 months to lengthen the rods to keep up with growth.

The growing rod technique has been utilized at Vanderbilt with good results for many years; however, last year a new technology became available—rods with magnetic expansion control—MAGEC rods. These are implanted the same way as the traditional growing rods, but they have an internal mechanism that can be lengthened using an external magnetic device in the clinic—a procedure that doesn’t require anesthesia or sedation. Martus said that some children with the traditional rods are candidates for having the rods replaced with the magnetic ones, depending on their age, size and other factors.

Overall, for these young children with severe scoliosis, the goal is to allow them to grow sufficiently until a definitive spine fusion can be performed, generally considered after age 10. So a 5-year-old with traditional growing rods that are lengthened twice a year might have 10 to 12 surgeries before the final surgery, Martus said. With the magnetic rods, the frequency of surgery will be less, but the implants may still need to be adjusted or replaced during the course of treatment.

Third grader Andrew Thomas of Columbia, Tennessee, is no stranger to Children’s Hospital or the operating room. He had a tough start to life. Born five weeks early with hypopituitarism, a rare disorder of the pituitary gland that can cause growth problems, and a congenital diaphragmatic hernia (CDH), a potentially life threatening disorder where the diaphragm doesn’t form completely, he spent four weeks in the Neonatal Intensive Care Unit, and then developed scoliosis at 18 months of age. He wore a brace for years, then as his scoliosis worsened, he wore a cast for three to four months at a time over two years.

His parents were relieved to find out that he could have his scoliosis managed with MAGEC rods instead of the traditional rods requiring surgery every six months. The 9-year-old was 2 inches taller when he came out of surgery to implant the rods in June. His rods were lengthened in October.

“He’s little and he always will be, but his mind works great and his body can do everything he wants it to do. He played baseball this spring and he’s an excellent student,” said his father, James. “He’s a good kid. We’re proud of him and we’re extremely thankful for the successful surgery and the amazing technology that has improved his life tremendously.”

Martus said children with scoliosis and other complex spinal deformities often have more than just isolated spine problems. “They may have other orthopaedic issues, and one physician on our team can provide all of their musculoskeletal care,” he said.

Like Christine Schueler, Andrew’s future might be influenced by his Children’s Hospital experiences. “Andrew is sweet, kind, thoughtful and funny,” said his mom, Jennifer. “He wants to be a pediatric orthopaedic nurse practitioner. He says, ‘I want to help kids like me.’”

– Nancy Humphrey