Limb Lengthening and Reconstruction – PediaCast 482

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  • Dr Christopher Iobst visits the studio as we consider limb lengthening and reconstruction. This amazing subspecialty of pediatric orthopedic surgery works hard to improve the lives of children and their families every day. Join us to learn more!

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  • Parenting with Science
  • Limb Lengthening and Reconstruction

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Transcription:

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We are in Columbus, Ohio.

It's Episode 482 for February 2nd, 2021. We're calling this one "Limb Lengthening and Reconstruction". I want to welcome all of you to the program.

Another interesting and important topic for you this week as we consider limb lengthening and reconstruction.

0:01:04

Now, these are things you probably don't think about every day.  And if that is the case, please do count yourself lucky because there are many kids and teenagers and families who do think about abnormalities of their arms and legs. And they think about these things often because these conditions affect the daily function of their extremities and impact the quality of their lives.

Maybe a condition the child is born with or one that is acquired as they grow. Might be the result of a traumatic injury, a serious infection, maybe cancer or its treatment. Whatever the case, they are in need of limb lengthening and or reconstruction which is a fascinating subspecialty of orthopedic surgery.

We have a terrific guest this week as we consider these conditions and their treatment. Dr. Christopher Iobst is here. He's a pediatric orthopedic surgeon with the Center for Limb Lengthening and Reconstruction at Nationwide Children's Hospital.

0:02:04

Before we get to him, you know science has definitely been in the news during the past 12 months, especially health and medical science as we consider and live through the age of a pandemic. SARS-CoV-2, COVID-19 illness and COVID vaccines have certainly been at the forefront of our attention. And I suspect that many of you have learned lots of medical science that you had not considered before. But there it is with a breaking news pretty much every day right there in front of us.

And that news has likely raised many questions, not just among adults and parents but also children. Questions like, where do medical recommendations come from? Why do these recommendations change over time? Do masks really work?

How do we figure out which medications are beneficial and which ones are not? How does COVID-19 affect the body? And why does it affect people in such different ways?

0:03:02

What is Messenger RNA? And what is the Messenger RNA vaccine? How are these vaccines made? Why were they approved so quickly? Are these vaccines safe?

In fact, you've probably asked yourselves more science related questioned and search for science related answers more so than at any other time in your life. Which leads us to another important point during this age of COVID. As we think about our role as parents, how are we doing answering our children's questions about the pandemic? Are we seeking evidence-based answers? Are we perhaps, in doing so, inspiring our children an interest and curiosity about science?

Now, of course not every child is destined to become a scientist. But for those kids who are asking questions and seeking lots of answers, a science career may very well be in your child's future. And if not science itself, their future will surely be impacted by science in one way or another regardless of which path their lives take.

0:04:07

And always keep in mind that our kids are watching us. So as we face these questions and concerns and we look up the answers to questions online, we're paying attention and really trying to get good resources, trustworthy credible sites on the Internet where we're getting our answers. And we're modeling that behavior for our kids, so hopefully then as they get older and they're asking questions and able to look up answers, they're also going to good credible sites to get those answers.

So, I was mulling on all of these, just thinking about how we are dealing with science during the COVID-19 pandemic and wondering how are we doing it inspiring an interests in science with our kids. And it struck me that here on PediaCast and on our sibling podcast, PediaCast CME, which is our Continuing Medical Education podcast for pediatricians and other healthcare providers, there are lots of topics, like today's for example, limb lengthening and reconstruction, that would probably be very interesting to many older children and teenagers just as a curiosity point on the way in which our world and living organisms work.

So, as we think back to all the topics that we've had over the last few years, just so many of them I think would be interesting to kids who are interested in science. So please do consider going back to the archive and listening to our podcasts with your kids and then talking about the topics we present.

Maybe looking up those topics on your own and finding other sites and resources that just sort of stoke that curiosity. And it's not really just an effort to inspire and stoke curiosity, it also hopes to establish empathy regarding the challenges that many children and their families face when they're dealing with particular disease processes and disorders that maybe are not common in your experience.

0:06:10

So, that thought process led me down the road of thinking how do we share and support an interest in science with our kids? So, I did some more web searching and curating of sites. And I found the collection of resources that I think really represent excellent places that parents could go if you would like to engage your kids with science.

So check out the Show Notes, I'm going to share those resources with you in a subsection of links called Parenting with Science. And here's what you're going to find, I'm going to put a link to PediaCast CME, in case you're not familiar with that program, again our Continuing Medical Education podcast. Lots of really interesting topics there. We do turn the science up. Sometimes, we use some terms and don't really explain them quite well because we figure there's kind of a base of pediatric knowledge there among listeners.

0:07:06

But I do think, especially if you're interested in science or your kids, especially older kids and teenagers who have an interest in medical science, I think you'd find some really fascinating topics to listen through over at PediaCast CME. So I'll put a link to that podcast for you.

Also, Common Sense Education. You may have heard of Common Sense Media before. They do a lot of reviews of movies and TV shows and video games, media that you consume from a parent's standpoint. What do those things really look like and are they advised or not advised? Again, Common Sense Media.

But they also have a sister site called Common Sense Education and its website reviews of educational websites. And so, you'll find tons of resources right there.

National Geographic Education is a great site. National Science Digital Library, the NASA Jet Propulsion Laboratory, so if your kids are interested in space or aerosciences, make sure that you check that out because they have lots of great resources for kids of all ages at the NASA Jet Propulsion Laboratory.

0:08:17

NOVA PBS KIDS, Climate Kids, the Smithsonian Science Education Center, the California Academy of Sciences, CK-12 to find STEM learning, OK Go Sandbox, Curiosity Machine, Zooniverse, Science Friday, Project NOAH, the list goes on. So many wonderful resources if you're interested in science yourself, if you want to share science with your kids.

And especially with school being a little bit disjointed during this pandemic, just supplementing your kids' education and getting them excited, finding science topics that excite them can be one way to really inspire them and to really promote their curiosity and investigational skills. But again, with sites and resources that are trustworthy, credible, evidence-based, all of those things.

0:09:06

So, again please do check out the show notes, Parenting with Science. I'll put them all of the links. Again, it's for this episode, 482 over at pediacast.org. But in the show notes for this episode, we'll put all those Parenting with Science links there for you.

A few quick reminders, don't forget, you can find PediaCast wherever podcasts are found. We are in the Apple and Google Podcast apps, also iHeartRadio, Spotify, SoundCloud, Audible, Amazon Music, and most other podcast apps for iOS and Android.

If you like what you hear, please remember to subscribe to our shows so you don't miss an episode. Also, please consider leaving a review wherever you listen to podcasts so that others who come along looking for evidence-based child health and parenting information will know what to expect.

We're also on social media. We love connecting you there. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.

And then, don't forget, if there is a topic that you would like us to cover on PediaCast, something that you would want to hear more about, maybe in your search of medical science sites, if there's a particular pediatric topic that you'd like us to cover, please do let me know. It's easy to get in touch. Just head over to pediacast.org and use that handy contact page.

0:10:15

Also, I want to remind you, the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

So, let's take a quick break. We'll get Dr. Christopher Iobst connected to the studio. And then, we will be back to talk about limb lengthening and reconstruction. That's coming up right after this.

[Music]

0:11:19

Dr. Mike Patrick: Dr. Christopher Iobst is a pediatric orthopedic surgeon at Nationwide Children's Hospital and an associate professor of Orthopedics at the Ohio State University College of Medicine. He specializes in limb lengthening and reconstruction in children. That's what he's here to talk about today. So, let's give a warm PediaCast welcome to Dr. Iobst. Thank you so much for stopping by.

Dr. Christopher Iobst: Thank you so much for having me. I'm excited to be here.

Dr. Mike Patrick: Really appreciate you taking time to chat with us. So limb lengthening and reconstruction is really a specialty within orthopedics, tell us a little bit about that.

Dr. Christopher Iobst: Sure. So the process will start with limb lengthening. Most of us are familiar with suffering a broken bone either in ourselves or family member. And typically, what happens is you get your broken bone placed in a cast and then the bone magically kind of grows back together again and you get your cast off.

0:12:10

What limb lengthening involves is that same process, except that instead of letting the bone just grow right back together again, we can actually slowly separate the two ends and the body naturally fills that gap with bone. And so, using different orthopedic devices, we can actually slowly lengthen the bone to correct limb length discrepancies and congenital conditions or patients who may have had injuries to their growth center from trauma or infection.

And so it allows us to reestablish equal limb lengths either in the upper or lower extremities. 

Dr. Mike Patrick: So these may be conditions that kids are born with. But then, they can also be acquired conditions or the results of a trauma. I mean it's really as I was looking at who get these procedures, the list just went on and on of various problems that can happen in kids where you might need limb lengthening or reconstruction.

0:13:07

Dr. Christopher Iobst: Yes, keeps us busy week after week. So you're right, you can be born with certain congenital conditions. So, one of the most common would be something called fibular hemimelia where a child is born without a fibula bone in the leg or a part of a fibula bone. And so it results in combination of deformities, as well as leg length discrepancy.

And then, there are many other ways that it can occur during the course of the growing years. So like you mentioned, an injury to where the bone grows to affects the ensuing growth over the years, or an infection that injures that growth center or even a form of cancer that involves a tumor involving the growth center. Those are all various ways that you can develop a leg length discrepancy over the course of your lifetime.

And then, we also take care of adults too in part of our center. So that even adults patients that may have a trauma where they end up with the leg length discrepancy were able to address their issues at the same time.

0:14:03

Dr. Mike Patrick: I'm going to list off just some names. And these are some of the disorders where folks may need your expertise and I only do it just to show folks the breadth of conditions. And lot of these are ones that maybe you've not heard of before and because they don't affect huge number of people. And yet for the families that are affected, their world revolves around it from time to time. And so, this is really important that we understand that there are lots of families out there who have challenges that many of us are fortunate enough not have.

So things like blount disease, congenital short femur, cubitus varus, femoral anteversion, you mentioned fibular hemimelia, brachymetatarsia. I'm going to struggle on some of these, genu valgum, hemihyperplasia or limb length discrepancy, radial club hand, tibial pseudarthrosis. That was kind of interesting one where there's a fracture and then, it doesn't heal properly. And so you have a sort of a fake joint there that can potentially be unstable and bend where the leg's not supposed to bend.

0:15:20

Fibrodysplasia, osteogenesis imperfecta which a lot of those affect adults as well as kids. And so,  there's really of conditions out there in which someone may need limb lengthening and reconstructions.

So, you an orthopedic surgeon, I would suspect there are also some non-surgical options when you have limb lengths discrepancies or deformities. Tell us a little bit about those. What do you try or do before you have to go to the operating room?

Dr. Christopher Iobst: Typically, the limb lengthening algorithm looks like this, there's basically five different choices that we offer any patient who walks in the door. Fortunately, no one has ever died of a limb length discrepancy. So you actually don't have to treat it.

0:16:05

So depending on the size or the amount of the discrepancy, just observing it and continuing your life without doing anything is an option. It's not the best option but certainly, it's a choice. Then we start getting into situations where we're trying to modify the shoes. So you can get a lift built into your shoe or lift that goes inside your shoe that kind of balances your leg lengths and that can certainly be continued into adulthood.

So again, if you have some particular fear of surgery and you don't want to have an operation, you could use a shoe lift in your shoe for the rest of your life and manage your leg length discrepancy that way. For many people that's also not a popular choice just because they don't want to have to constantly modify their shoes and buy new shoes that have the lifts built into them. And at some point, if your discrepancy is big enough, the lift gets so large that it just gets to be kind of cumbersome to walk on such a big lift.

And then, there are certain small procedure that we can do where we can actually modify your growth by slowing down the growth on the longer limb. So then, a small outpatient surgery can be performed where we basically target one or two growth centers in your limb and slow the growth at that particular site, which allows the short limb to catch up. The idea being that at the inner growth, your leg lengths are essentially equalized.

0:17:21

And then, you get into the bigger surgery which involve leg lengthening of the shorter limb, which we can talk about in more detail later.

Dr. Mike Patrick: I love how you put that, that you can either operate on the shoe or you can operate on the leg. Because you are making adjustments one way or the other.

And you mentioned no one dies of a leg length discrepancy but, on the other hand, it really can alter function, right?

Dr. Christopher Iobst: Right.

Dr. Mike Patrick: And so the quality of life can certainly make a big difference in our decisions of whether to be more conservative or to do a surgical therapy.

Dr. Christopher Iobst: Right, right. I didn't want to sound to flippant with that remark, but basically in terms of what we see in the office, fortunately, they're not life or death decisions. But you're right, having a leg length discrepancy certainly can cause functional deficits. And we know pretty clearly that for certain larger discrepancies, if you don't do anything, you're at risk for developing low back pain, hip pain or knee pain as an adult person.

0:18:19

Most people don't realize that almost all of us do have a small difference in our leg length. It's actually more uncommon to be completely symmetric than it is to be slightly asymmetric. But as long as that difference remains in a small amount, it really doesn't affect your overall function. But once you sort of reach a threshold, which is depending on the size of the patient can be anywhere from a centimeter and a half to two centimeters of difference, then we feel like it's important to intervene and provide some sort of treatment.

Dr. Mike Patrick: As you're walking families down the road of this decision, how do you help them make that? I mean, when should families really consider surgical treatments for this?

Dr. Christopher Iobst: It's a very personal decision, like I said, in some particular situations where we don't even operate, where we just manage it with a shoe lift.

0:19:05

But in general, once the discrepancies start to interfere with your function in some ways, so in some of the congenital conditions, where the discrepancies can be quite large, certain compensatory maneuvers develop in the kids. So in order to walk more evenly, they'll kind of tiptoe on the short leg or they'll have to bend their knee on the long leg. So they start to have problems with their gaits.

Certainly, they start to have discomfort or interferes with their ability to play sports, reduce certain activities or just play with the other kids. Then that starts to make it an easier decision about when we should intervene because, certainly, we want to try to correct some of that and get them back as close to normal as possible.

Dr. Mike Patrick: Now, once a family has made that decision, "Okay, we're going to go ahead and go with surgery," I know that there are some sort of traditional treatment options that have been available. And then, there are some newer ones. Let's start with the traditional options. How has limb lengthening been accomplished particularly in the past?

0:20:06

Dr. Christopher Iobst: Okay, thank you. Traditionally, it's done with a device that's attached to the outside of the limb. So we talked about at the beginning of the session that we need to slowly separate the two pieces of bone to allow the new bone to form in between.

So the device that allows us to do that is basically called an external fixator. So it's like a ring that goes around the limb and is attached to the limb with some pins or wires. And then, that device can actually be distracted or lengthened. And so, it slowly pulls the two bones pieces apart.

And so it's extremely effective in doing that job but it was also always something that we were looking to improve on because having a device outside the limb implies that it's going to be relatively uncomfortable for the patient to get around, especially if it needs to be in place for several months at a time.

Dr. Mike Patrick: And there would also be a track then for infection, if there's a skin bacteria, if you have metal rod that goes to the skin and in the bone, there's a track there for bacteria to get in. So I suspect that there's also infection risk when you have external appliances like that.

0:21:15

Dr. Christopher Iobst: Absolutely. So we call them pin site infections and they're basically universal. So when we do one of these devices, we basically explain to the family that you are going to get a pin site infection during the course of treatment and just consider it normal. And we'll take care of it when it happens. But absolutely, it's definitely an annoyance with this type of devices that we have to constantly deal with that issue.

Dr. Mike Patrick: Now, as you're pulling bone sort of apart and encouraging it to grow, how do you get the bone to look like a bone when it's done growing?

Dr. Christopher Iobst: Great question. Well, it actually has to do, so we consider ourselves bone farmers, right? We're trying to grow bone and so you need to water the bone and you need to get the right amount of sunlight and that involves several factors.

0:22:03

So number one, the timing of when you're actually start to pulling the bone apart is important. So, we actually let the bone start to heal just slightly before we actually start the lengthening process. So from the day of surgery to the day they start the lengthening could be a week of time before they start, so that's important.

Number two, the speed with which you actually separate the bone is extremely important. So, if you pull it apart too fast, then it can't make enough bone and so it doesn't fill in the gap. If you pull it apart too slowly, it can actually heal itself back together too quickly and then you can't pull it apart.

So, during the lengthening process, we see the patients every week in the office because we need to keep a very close monitoring of this lengthening process. And on the X-ray, we look at how the bone is forming and we can either slow it down or speed it up depending on what we see.

And then, finally, having the patient do weight bearing, so standing and putting weight on the limb is extremely important in helping that new bone to grow and heal and form normal looking bone.

0:23:04

Dr. Mike Patrick: Yeah, very interesting.  So just let me kind of sum this up to make sure that I have it straight. And I think this will help our listeners as well. So, if there's a bone that you want to lengthen, so traditionally, you would a fracture in the bone so you have to sort of disconnect, have a cut all the way to the bone.

And then, you have rods that are drilled into the bone and come outside the skin on each side of that fracture. And then, as you move those apart, then you're asking the bone to sort of fill in with new bone as you're moving that. Is that a good…

Dr. Christopher Iobst: That's a very good description of it, yes.

Dr. Mike Patrick: Okay. And then, just so folks understand, it can become more complicated because, especially when you're talking about limb reconstruction, bones are three-dimensional objects. And so, sometimes, there can be an issue with the bone maybe being rotated one way or the other.

And so, you may need to encourage the bone not just to grow straight, you may need it to grow in a particular way or directions. And then, you manipulate those external devices to shape the bone as it's growing, which is way more complicated than it sounds, right?

0:24:11

Dr. Christopher Iobst: Yeah, it's actually pretty rare that we encounter patients that just need straight lengthening, that would be the ideal patient. But much more often than not, they also have some additional associated deformity with it, so like you mentioned, either rotation or angular deformity or some sort of translational deformity.

So, it is a very three-dimensional project that we work on in order to get the bone architecture kind of back where it needs to be. And so, in the process of lengthening, we're oftentimes simultaneously correcting either angulation or rotation.

Dr. Mike Patrick: And the bone is a new bone growth from the patient. Are there ever instances where you need to do a bone graft or use some sort of synthetic material in this process?

Dr. Christopher Iobst: So, that's certainly described in the literature and it tends to be more of a concern in the older adult patients. So fortunately, young healthy children typically make great bone and we usually don't need to augment it in any way.

0:25:12

In our center, again, because we're so diligent about keeping track of how the bone is forming by seeing the patients every week in the office, we almost never have to do that type of thing. But in adults that have other medical comorbidities that affect bone healing, then sometimes, that is an issue.

Dr. Mike Patrick: So then, we talked about sort of a classic way that these deformities have been treated. But there's really, the field is moving towards some advance techniques. Tell us about those.

Dr. Christopher Iobst: Right. So these external devices which have been in place for the last 50 years, again, they are dramatically successful in doing what they need to do. But we were always searching for better ways because again, it was outside the bone and you have this pin site issues and other just uncomfortable issues at having the fixator attached outside he limb.

0:26:05

So, we've come up with a new device within the last five to ten years that allows us to do all the lengthening from inside. So it's actually an implant that goes inside the bone. It's attached to the bones with some screws on either side of your surgical separation.

And then, that device is actually is telescopic so that it can gradually lengthen. And so, there are essentially two different devices on the market right now, but each lengthens with a slightly different manner.

One uses a magnet and the other uses radio frequency. But basically, the patient goes home with a little handheld device that they put over their limb and it communicates with the implant inside the bone. And it allows it to do the lengthening basically invisibly because it's all happening inside.   

Dr. Mike Patrick: So in this case now, instead of having the metal rods drilled through the bone and coming out the skin and then connected to something that then can move them apart, this is just a single rod down the center of the bone, down the length of the bone. And then, you're able to separate the two halves of bone by making that longer or shorter.

0:27:14

Dr. Christopher Iobst: Correct. So, if you again think three dimensionally about your bones, so your bone is sort of hallow in the inside where your bone marrow sets. So this implant, we call it a nail or rod but it fits inside that hallow part of the bones, so you don't see it or feel it. And it just telescopes and can get longer or shorter actually depending on what you're trying to do with it. And it allows the lengthening process to all happen from the inside.

Dr. Mike Patrick: Great. And so nothing comes out through the skin. This is just once you have the surgery, the skin is closed up and this thing is inside.

Dr. Christopher Iobst: No, this is beautifully sophisticated and elegant. It's all inside.

Dr. Mike Patrick: Great. Now, does it stay inside or once the process is complete, is that nail or rod or pin removed?

Dr. Christopher Iobst: In general, we recommend removing it simply because it's like having a little tiny machine inside your limb. And we just feel like it's not a good idea to keep that for the rest of your life. So typically, an outpatient surgery is done, 9 to 12 months after it's inserted, to just go back and remove it.

0:28:13

Dr. Mike Patrick: Got you. The bone marrow has a job to do. It makes blood cells. Does having that in the bone marrow cavity, does that alter the bone's other jobs?

Dr. Christopher Iobst: It does not. First of all, it's only filling part of the canal, not the entire canal, so there's still room for that to happen. Second, it's only temporarily inside you, so like we just talked about, after nine months or so, it comes right back out.

And then, third, it's only one bone that we're using. So, all your other bones still function as bone marrow producing areas.

Dr. Mike Patrick: Yeah, very fascinating. And for those of you out there that are like me, need a little more visual of what this all looks like, I did find a great site, the International Center for Limb Lengthening at the Sinai Hospital of Baltimore. And they have a really nice descriptions and pictures and resources. I'm just going to put a link to that in the show notes, so folks can find it if you're having trouble visualizing what these things look like.

0:29:12

Now, I imagine as parents are listening to this, there's probably some squeamishness out there as you think about this. What are the risks involved in all of these? I'm sure that parents would ask you this all the time. Like we understand the benefit, we're going to get our limbs equal, we're going to improve function, improve quality of life. But there must be some risks with doing this, what are those?

Dr. Christopher Iobst: Sure. I like to describe it as if we were just walking skeletons, so if we didn't have skin or muscle or any soft tissue over your bones, we could lengthen you to be 20 feet tall. So making new bone and making the bone longer is not really the issue. It's the fact that your bone is surrounded by a soft tissue envelope and that soft tissue is actually what limits how much stretching we can do.

0:30:05

So, as we start to lengthen the bone, everything else has to get longer with it, your muscles, blood vessels, your nerves, arteries, everything. So we generally involve a very rigid course of physical therapy during the lengthening process to make sure that the joints above and below the bone that we're working on maintain their range of motion and their flexibility.

So in terms of what could potentially go wrong as we're lengthening, if the muscles start to get tied, if they start to have difficulties straightening or bending their knee fully, then it may indicate that we're reaching the limit of how much we can stretch the tissue and we need to slow down or stop the lengthening and then potentially do it again later in the future.

That's the major concern really with limb lengthening is that you could create issues with contractures of the joints or in the worst-case scenario, dislocate a joint. But again, in our center, because we're so vigilant with our patients, we catch these things early and prevent them from happening.

0:31:05

Dr. Mike Patrick: Great. And then, of course, the usual risk that go along with surgery, so anesthesia, bleeding, infection. But those were certainly no greater with this sort of surgery compared to other surgeries that you do, correct?

Dr. Christopher Iobst: No. In fact, the incisions to do the surgery are remarkably small. So we talked about that we needed to separate the bone or create a surgical fracture there. And we can actually do that through basically a 5-millimeter incision. So it's just a tiny tiny little opening in the skin. And so, the surgeries are generally pretty safe.

Dr. Mike Patrick: Is it more difficult to get the pin out than to put it in? Or is it about the same?

Dr. Christopher Iobst: If we get it out at the 9 to 12-month mark, it's generally not an issue. The longer it stays in, the more bone tends to grow over some of the screws and it can be harder to get them out, but in general, it's not a big deal.

Dr. Mike Patrick: So, now when we're talking about pins and nails and rods and bones, that certainly sounds like something that would be painful. Is it something that the kids experience or do we have ways to keep that pain under good control?

0:32:08

Dr. Christopher Iobst: Excellent question. So we get this all the time. Parents have a lot of concerns about "Do I want to subject my child to this type of procedure?" because it sounds like medieval torture that you're pulling on somebody's limb and making it longer.

And with the new devices that we mentioned that go actually inside the limb, the process of lengthening is so gentle and so small with each session that it's almost painless.

So, typically what happens is the kids might take pain medicine for a few days around the time of surgery. But once they get into the limb lengthening process, they're so comfortable that at most, they take Tylenol or some kind of over-the-counter pain medication or nothing.

And in general, it's an extremely comfortable process. So it just doesn't seem like that would be case but it actually is very very pain free.

0:33:03

Dr. Mike Patrick: And kids aren't afraid to tell you when they're hurting. So, you really get a good indication that this is something that they're able to tolerate very well.

Dr. Christopher Iobst: Right, right. In fact, if we have someone with discomfort, it's almost like an indication like, okay, something must be going awry because typically that is not the case at all.

Dr. Mike Patrick: Good to know. And then, in terms of post-operative care and rehabilitation, I mean you've got this bone, I would imagine it's a little more fragile at first until it kind of matures, perhaps. And correct me if I'm wrong on this, but are they a little bit more risk for fractures or issues with the bone? What kind of rehab goes along with them healing?

Dr. Christopher Iobst: Sure, great question. So with the new technology, the implant that we just discussed, the rod or the nail that goes inside the bone, it actually is protecting that new bone the whole time because you have this metal rod inside the bone. So fracture's not so much of a concern.

0:34:01

We do get the patients up, regardless of the device whether internal or external, we get the patients up on day one after surgery. We want them up, like I mentioned, weight bearing is extremely important for helping the bone heal. So at no point are they bedridden or stuck in a wheelchair for extended periods of time. They're actually up and moving immediately.

And then, just in terms of the rehab, we talked about that physical therapy is important, so they get physical therapy. Basically, they have a home program that they need to do every single day. And then, they're monitored with therapy visits when they come to clinic, just to make sure that they're maintaining their range of motion.

And then, initially, they're not fully weight bearing. They're sort of partial weight bearing, just again, protect the new bone as it's forming. And then, gradually, as we check on the X-ray and see that it's getting stronger, we allow them to bear more and more weight until they're walking fully without assisted devices.

Dr. Mike Patrick: That's really really fantastic. And, of course, when we think of this, in the beginning, we talked about all these different diseases where someone may need your services.

0:35:06

And then, we've been sort of discussing more just the limb length discrepancy and lengthening it for some folks. But there's more involved techniques and surgeries that you may have to do for those with deformities. We also know that these kids really benefit from physical activities just like we all do, aerobic activity and doing strength training and those sorts of things.

And so, there may be obstacles that the folks with adaptive sports medicine can help out with to encourage kids with limb deformities to continue to be active. And I just wanted to mention to folks, if you're interested in hearing more about that, we talked with our Sports Medicine folks in Episode 434 on adaptive sports medicine. And we'll put a link to that in the show notes for this episode over at pediacast.org as well.

And so then, are these typically just one-time surgeries? Do you ever have to, once you've got the bone, the length that you want it to be, whatever caused it to grow more slowly to begin with, could that be a problem again down the road? Or do you do this sort of at the end of their skeletal maturity? Or is this a one-time deal or you have to go back and do it again?

0:36:23

Dr. Christopher Iobst: It really depends on what brings you to the table, so what caused your leg length discrepancy in the first place. So for the congenital children, oftentimes, it will require multiple lengthenings over the course of their lifetime because their overall discrepancy is just so large that you can't accomplish it in one sitting.

And so, the bone has this remarkable capacity that you can lengthen it and then relengthen it again at a later time. And so, we try to space this out so that the kids aren't constantly having surgery all the time.

And so, with the newer devices, we can sort of schedule their surgeries every three to four years or some interval of time like that, and just chop away at the leg length discrepancy until we slowly get it to its equalized length. So it can take three or four lengthenings in certain kids, depending on how much discrepancy is their total.

0:37:16

Dr. Mike Patrick: And then, each time that happens, we're talking about at 9 to 12-month process with the rod in there?

Dr. Christopher Iobst: Actually, much faster. Well, 9 to 12 months in terms of from the day that rod goes in to the day it comes out. But in terms of actually lengthening and getting back to walking, fully weight bearing without assistance is more on the four to six-month period of time.

Dr. Mike Patrick: Great. And then what about during adulthood? So folks who have had these procedures as children, what is function like moving forward? And are there any issues that would have to be addressed later down the road?

Dr. Christopher Iobst: Well, when we design a life plan for the patients, our goal is to try to get their leg lengths balanced and their limb alignment corrected by skeletal maturities, so by the time they finish growing.

0:38:04

And so, if we're able to accomplish that, then as an adult, you should be fully balanced and functional and it should never recur. Your leg length difference won't re-accumulate once you're done growing.

And we talked about that it's normal healthy bone that forms in there, so it should just stay formally corrected. And hopefully, we hope that our patients move into adulthood and don't have any long-term consequences.

Dr. Mike Patrick: Now, this definitely sounds like very specialized procedures. Are these sorts of services available all over the place? Or is it really limited to particular children's hospitals? 

Dr. Christopher Iobst: This is a very unique sort of niche within orthopedics. And so, there are not a lot of places that provide this, at least not as a full-time limb lengthening center like we have at Nationwide Children's Hospital. So we're sort of unique in the sense that we have this as a free-standing full operating center.

0:39:04

But most of the major metropolitan areas around the country have at least one surgeon who does this kind of work. So you can find him or her in most of the big cities. But it's really not everywhere. And even some of the big cities out there have big voids where this type of orthopedic care is not provided.

Dr. Mike Patrick: And for folks who may not have a good center near them, here at Nationwide Children's Hospital we would be happy to see you, right?

Dr. Christopher Iobst: Absolutely, yes.

Dr. Mike Patrick: And I'll put a link in the show notes so folks can find the Center for Limb Lengthening and Reconstruction at Nationwide Children's.

And I would imagine, you mentioned that there may just be a solo surgeon in an entire big metropolitan area who does this. I mean, we really have an entire team that works at this with multidisciplinary approach. Tell us, who are the members of your team?

Dr. Christopher Iobst: Right. In order to call ourselves a center, it implies that we actually have a whole team. And so, what we like to provide is full service for each family and their patient when they come to see us.

0:40:09

I mentioned already that we have a physical therapist as part of our team. So, when they come to see us in the clinic, they don't have to schedule a separate physical therapy visit or travel somewhere else to get their therapies. It's actually right there at the same center.

Therapist is able to discuss the care who with us directly, provide immediate feedback which is critical to helping these patients get the best outcomes.

As you can imagine, there's a lot of kind of unusual X-rays that need to be obtained and so we have trained X-ray technicians as part of the center. The same people are there every day taking these X-rays, so they're very good at getting the appropriate images for us. That's also right on site.

We have a nurse practitioner who works with us who's fully trained in limb lengthening and limb reconstruction type of patients. We have a nurse as part of our team. We have a whole research staff.

What's also unique is that we actually have a team psychologist involved. So part of limb lengthening is that it's sort of a long journey. It  takes several months for you to go through it even in the most smooth outcome.

0:41:14

And so, just that long duration of treatment can be kind of taxing on the family or on the patient. And so, having a psychologist available to help them kind of work their way through any kind of issues that occur along the way is extremely helpful. And it's also very rare for a lot of centers out there.

Dr. Mike Patrick: Absolutely. So really remarkable center and would be happy to take care of anyone from around the country. And I will put a link again to the Center for Limb Lengthening and Reconstruction at Nationwide Children's in the show notes, also link to that episode on adaptive sports medicine, PediaCast Episode 434.

So Dr. Christopher Iobst with Pediatric Orthopedic Surgery and a surgeon with the Center for Limb Lengthening and Reconstruction at Nationwide Children's Hospital, thanks so much for stopping by today.

Dr. Christopher Iobst: I appreciate it. Thank you for having me.

0:42:02

[Music]

Dr. Mike Patrick:  We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that.

Also, thanks to our guest this week, Dr. Christopher Iobst, with Pediatric Orthopedic Surgery and the Center for Limb Lengthening and Reconstruction at Nationwide Children's Hospital.

Don't forget, you can find this really wherever podcasts are found. We are in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Audible, Amazon Music, and most other podcast apps for iOS and Android.

0:43:01

Our landing site is pediacast.org. You'll find our entire archive of past programs there, along with show notes for each of the episodes. Our Terms of Use Agreement and that handy contact page if you would like to suggest a future topic for the show.

Don't forget, reviews are helpful wherever you get your podcast. We always appreciate when you share your thoughts about the show. And we love connecting with you on social media. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.

I mentioned PediaCast CME in the introduction to today's episode. That's our Continuing Medical Education podcast for pediatricians and other healthcare providers. It's similar to this program. We turn up the science a couple notches and offer free Category 1 Continuing Medical Education Credit for those who listen. And that includes doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, even dentists.

And since Nationwide Children's is jointly accredited by many professional organizations, it's likely that we offer the exact credits that you need to fulfill your state's Continuing Medical Education requirements.

0:44:08

Shows and details are available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.

Thanks again for stopping by and until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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