Surgical correction of early-onset scoliosis no longer requires multiple procedures over the course of several years. At Gillette Children’s Specialty Healthcare’s Pediatric Orthopedics program, specialists utilize an advanced magnetic system to deliver a less invasive treatment that enhances the patient’s quality of life.
The pediatric focus at Gillette Children’s Specialty Healthcare cultivates an environment that fosters expertise in rare and complex childhood-onset conditions. When treating conditions complicated by a child’s growth, experience is critical.
“The population is so unique and the knowledge and skill set require repetition when it comes to managing and surgically correcting such conditions,” says Tenner Guillaume, MD, a board-certified orthopedic surgeon specializing in spine surgery at Gillette Children’s Specialty Healthcare. “It’s better handled by individuals in a specialty center who are frequently treating these issues.”
Surgeons adept in managing pediatric scoliosis are equipped to incorporate Magnetically driven Growing Rods (MdGR) into surgical intervention to correct a child’s abnormal spinal curvature after nonsurgical management fails. Providers at Gillette Children’s Specialty Healthcare were the first in the region to treat early-onset scoliosis with the system, and they use similar mechanics to treat limb-length deficiencies of the femur, humerus and tibia.
“The most important thing about Gillette Children’s Specialty Healthcare is that all our specialists are located in one building, allowing for seamless multidisciplinary care. Our physicians are focused on restoring or maintaining our patients’ function and abilities, and our level of expertise makes our hospital unique in that regard.”— Tenner Guillaume, MD, a board-certified orthopedic surgeon who specializes in spine surgery at Gillette Children’s Specialty Healthcare
Growing With Children
Before treatment with Magnetically driven Growing Rods
Building upon the innovative use of magnetic technology to correct limb-length discrepancies, MdGR systems for scoliosis treatment consist of rods, fixation components and a handheld external remote controller. A magnet within the rods reacts to a larger magnet inside the external remote control. During a two to three-hour procedure, Dr. Guillaume makes one incision at the top of the spine and one at the base, through which he inserts and anchors rods above and below the abnormal curve. Radiographic imaging guides the procedure, enhancing the accuracy of placement as well as the long-term efficacy of the operation.
To control an abnormal curvature while accounting for a child’s growth, conventional surgical management for early-onset scoliosis requires repeat surgeries as often as every six months after the initial procedure.
“Such courses of treatment disrupt both the child’s and his or her family’s lives,” Dr. Guillaume says. “Children miss school, and their parents take time off work to be with them during their hospitalizations. MdGR is far less disruptive.”
After treatment with Magnetically driven Growing Rods
Surgeons direct the amount of distraction, which is generally in the order of 6 millimeters per lengthening. While patients lie on their stomachs, Dr. Guillaume places the remote control on their backs. The magnet within the remote control activates the smaller magnet and a micro-motor inside the implanted rod, causing an expansion of 6 millimeters. Dr. Guillaume typically looks to lengthen a patient’s spine one inch every year to account for his or her natural growth.
Most importantly, the quality of patients’ and their families’ lives is kept in mind just as much during treatment as after.
“The spinal care we provide at Gillette is patient- and family-centered. Our goals are always going to be improving quality of life and outcomes and minimizing risk and inconveniences associated with the treatments,” Dr. Guillaume says. “Any decision we’re going to make, we’ll make after spending time educating our patients and their families. We’re going to make the decision together, and it’s going to be the decision that is best for the patients and their families.”
The Essential Evaluation
Dr. Guillaume performs an adjustment on a patient.
Patients between the ages of 5 and 10 who have progressive spinal curvatures benefit the most from surgical intervention with MdGR. This is because, according to Dr. Guillaume, they are less likely to require a second set of rods before they are fully grown.
The initial examination to assess the indication of MdGR for each patient begins with a detailed physical examination. Providers scrutinize imaging studies, measure limbs and spinal curvature, conduct a comprehensive patient interview, and establish a timeline of the condition’s progression.
When Dr. Guillaume approves use of MdGR, he has the support of Gillette’s more than 25 orthopedic surgeons and nurse practitioners, as well as a multidisciplinary team of experts — all with extensive pediatric training — in cardiology, neurology, intensive care, radiology, rehabilitation medicine, assistive technology, gait and motion analysis, and physical therapy.
Collaboration is essential to account for all aspects of the child’s condition, as a few conditions contraindicate MdGR. The FDA has not approved the modality for use in patients who have pacemakers, and it is unknown if the system is safe for patients who require repeat MRIs.
Lengthening Limbs
Motorized intramedullary limb lengthening was pioneered by Rainer Baumgart, MD, who developed the FITBONE device in Munich, Germany. This modality leverages radiofrequency waves sent painlessly from a transmitter to a receiver implanted under the skin. A micromotor inside the implanted lengthening rod is adjusted in tiny increments with this remote controller 3-4 times a day.
Magnetic intramedullary limb-lengthening systems utilize magnetic technology to treat limb-length discrepancies via a similarly painless process. The device is lengthened with an external hand-held remote controller that sends magnetic signals to a tiny magnet inside the implanted device.
(Above) Dr. Dahl correlates the X-ray image of the anatomy to be lengthened with the magnetic intramedullary limb-lengthening system he plans to use. (Below) A close-up view of the system.
Mark Dahl, MD, an orthopedic surgeon specializing in limb-length discrepancies at Gillette Children’s Specialty Healthcare, has used both radiofrequency and magnetic devices on the femur, tibia, and humerus more than 200 times in the past six years with excellent results, decreasing pain and scarring in children and adults.
“The difference between bone lengthening and spine lengthening is the timing between adjustments,” Dr. Dahl says. “When treating a limb deficiency, we make incremental adjustments three or four times per day, compared with once every three months for spinal correction.”
The difference is attributed to the fact that scoliosis correction does not require growing new bone, Dr. Dahl notes. This permits specialists such as Dr. Guillaume to correct a larger percentage of the deformity in a faster period of time in the clinic.
“Surgical intervention for limb-lengthening correction requires the surgeon to create a low-energy fracture in the bone during surgery,” Dr. Dahl explains. “Once the fracture starts to heal, we use the magnetic lengthening system to tease the fracture apart little by little to encourage the body to bridge the gap created by the small fractures with new bone.”
The surgical process is also guided by preoperative imaging scans that form a digital map of the bone. Preparation permits Dr. Dahl to know precisely what to expect in terms of the anatomical positioning of blood vessels, tendons and nerves.
Weekly follow-up appointments allow Dr. Dahl to keep patients on track with their care plans and mitigate any complications that may occur. In 50 days post-op, a child’s limb may be lengthened 2 inches. During the lengthening process, children undergo a rehabilitation regimen that includes stretching to keep the joint moving.
Dr. Dahl teaches parents how to use the remote control and marks the child’s limb to indicate where it should be placed. At home, parents place the remote on the limb and hold the device’s button for 90 seconds, effecting a quarter-of-a-millimeter distraction in the bone. They repeat the process three to four times a day.
After the initial eight-week period of frequent follow-up, Dr. Dahl sees patients once a month for two to five months.
Family-centered Aim
While restoring functionality and enhancing quality of life are chief among the concerns of Gillette Children’s Specialty Healthcare’s physicians, the wide-ranging effects such innovative treatments may have on patients’ families also factor heavily.
“The treatments we deliver are beneficial to patients and families for so many reasons, including minimal disruption to everyday life and enhanced correction,” Dr. Guillaume says. “The fact that we perform these procedures is a boon to the Twin Cities and the rest of our coverage area.”
The Steps after Surgery
Just as specialists in the pediatric orthopedics program conduct patient evaluations and preoperative planning with extreme precision, specialists in the hospital’s pediatric rehabilitation program design therapy plans that leverage the most advanced techniques and technologies.
The therapeutic services delivered in the inpatient setting and at outpatient clinics include physical, occupational, speech and language therapy, as well as aquatic therapy, audiology assessments, and nutrition and feeding therapy.
For patients who have undergone surgery for early-onset scoliosis or limb-length conditions, therapists focus on augmenting the surgical procedure through strengthening joints and muscles. In cases of scoliosis, abdominal and back muscles can tighten or become weak, while for patients with limb-length discrepancies, tightness in the joints can be avoided with a program of stretches.
Wide-ranging Capabilities
Gillette Children’s Specialty Healthcare is one of only three pediatric specialty programs in Minnesota accredited by the Commission for Accreditation of Rehabilitation Facilities (CARF) to meet the needs of young children and adolescents seeking acute inpatient rehabilitation. Gillette has been CARF-accredited since 1992.
Rehabilitation therapists are as versed in caring for broken arms and concussions as they are in contributing to long-term care plans for conditions such as cerebral palsy. The rehabilitation team regularly collaborates with specialists in craniofacial and plastic surgery, orthopedics, radiology, rehabilitation medicine, and social work.
For more information or to refer a patient to Gillette Children’s Specialty Healthcare’s Pediatric Orthopedics program, visit gillettechildrens.org.
Source : MD NEWS , 25th Jan 2016
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