<img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2006-05_02/f-2-1.gif" hspace="4" vspace="4" /> <b><i>The idea of internal prostheses for children isn't new. For more than 20 years, surgery to remove bone cancer tumors from pediatric patients often has included an implant to replace the missing bone in the child's arm or leg-a welcome alternative to the limb amputations that once were considered the best solution in such cases.</i></b> <b><i>Due to improved treatment options over the past few decades, including chemotherapy and radiation, such implants increasingly have replaced amputations for children suffering from bone sarcomas. The process, however, also has required payment of a painful annual premium for such children: The implanted prostheses don't grow, but the children who carry them do.</i></b> To prevent uneven arm or leg lengths as the child develops, additional surgeries are required on a more or less annual basis-depending on the individual child's growth ratein order to replace the old prosthesis with a newer one, sized to match the child's current leg or arm length. Things, however, are looking brighter for such children. The recently developed expandable prosthetic implant allows length adjustments to be made through a simple, non-surgical outpatient procedure. The REPIPHYSIS® Expandable Implant is identified by its maker, Wright Medical Technology, as the only non-invasive expandable endoprosthesis available in the US. Originally developed in France, the implant consists of a spring-loaded coil housed inside two hollow tubes. When the prosthesis is initially surgically implanted, the spring is immobilized by solid plastic that surrounds it. <table border="0" width="250" cellspacing="0" cellpadding="8" align="right" bgcolor="#D2E4C3"> <tbody> <tr align="center"> <td> <h3 style="margin-bottom: 0px;">ACA Offers LLEAP for Children</h3> </td> </tr> <tr> <td><img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2006-05_02/f-2-2.gif" hspace="4" vspace="4" /> The Amputee Coalition of American (ACA) has prepared an educational program for children called LLEAP (Limb Loss Education and Awareness Program) which addresses the issue of the social stigma experienced by children with disabilities, particularly those with a limb difference. The curriculum is based on the premise that children can be taught to recognize and appreciate differences in themselves and others. Through a sequence of multi-sensory activities, children will: <ul> <li>Realize that individuals are more alike than different</li> <li>Identify their own strengths and attributes</li> <li>Develop an appreciation for the strengths and accomplishments of other people</li> <li>Explore interdependence and the nature of the helping relationship</li> <li>Become aware of how limb loss/limb difference might affect daily activities</li> <li>Appreciate the strengths and accomplishments of individuals with limb loss/limb differences</li> <li>Understand the types, functions, and limitations of prostheses</li> </ul> With more than 20 classroom activities, the curriculum can be adapted for use with children from preschool through sixth grade. For information visit <a href="https://opedge.com/531">www.amputee-coalition.org/publications_lleap.html</a></td> </tr> </tbody> </table> When the child's growth requires a length adjustment, however, the plastic is subjected to a dose of heat generated by a powerful electromagnetic field, and is thus softened sufficiently to release the spring and allow the prosthesis to "grow" in length to match the child's current need. Remove the electromagnetic trigger, and the plastic cools and again immobilizes the spring from further expansion until the next time the procedure is warranted. Joel Mayerson, MD, an orthopedic oncologist, is director of Musculoskeletal Oncology at the Arthur G. James Cancer Center and an assistant professor of Orthopaedic Surgery at Ohio State University. He also serves as co-director of the Bone Sarcoma Clinic at Columbus Children's Hospital. Mayerson notes that since the REPIPHYSIS was introduced about five years ago, about 150 of the implants have been introduced into young patients in the United States. Mayerson himself has implanted five of them, including, in July 2002, the first full-length femur extendable prosthesis used in this country. Since the process is so new, participating physicians are in the early stages of identifying any long-term or far-reaching effects on patients, he points out, but notes that outcomes are certainly being closely followed. It seems evident that the advantages currently far outweigh the negatives: "The REPIPHYSIS allows children to develop more naturally, with equal leg lengths," says Mayerson. And although the periodic adjustment procedure does generate the heat required to allow the implant to expand, and therefore the leg feels warmer to the touch, patients feel no discomfort, he reports. No technology is perfect. As with other medical advances, there also is room for improvement in the REPIPHYSIS, Mayerson believes. "A prosthesis made to fit an eight- or nine-year-old child may expand to new lengths as he ages, but it doesn't grow similarly in strength and breadth," says Mayerson. "The stem is going to be very small for an adult, so that creates some challenges. We'll just have to wait and see." Under the greater stresses of adult weight, there could be a greater risk of the child-sized implant breaking. In this case, says Mayerson, it would be replaced with an adult prosthesis that hopefully would be permanent. <h4>Advancing Technology</h4> <img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2006-05_02/f-2-3.gif" hspace="4" vspace="4" /> Michael D. Neel, MD, orthopedic surgeon and clinical assistant professor in Orthopaedics at the University of Tennessee, Memphis, also has been surgically implanting the expandable prostheses for pediatric patients at St. Jude Children's Research Hospital. Neel summarizes the evolution of the implant. "Traditionally, if the osteosarcoma were at the end of the thigh bone and top of the shin bone, which is where they most commonly occur, that required an amputation-that was in the 60s. Then, in the 70s, they started doing limb salvage, cutting out the bone that had the cancer in it, and doing a bone graft, or some related procedure, to reconstruct the defect so you still had a mobile knee-or a knee fusion. "In the late 70s and 80s, a prosthesis was developed that would allow you to reconstruct the joint. Instead of having a big gap from the end of your thigh bone, it would be all metal, connected to a metal piece that was anchored to the top of the shin bone. These two pieces were anchored together with appropriate components to create a mobile knee joint-a modular oncology prosthesis. This preserved a bendable knee and foot for the patient." Neel continues, "In some cases, if the cancer doesn't involve the articulating portion of the bone, but rather the mid-section, we can reconstruct that with an intercalary bone graft. The idea is that the patient's function is better, and the prosthesis will thus last longer, if you save the joint. If you can't save the joint, then you have problems with the fixation of the prosthesis to the bone. It can wiggle loose over time, which then destroys some of the bone, leaving less bone for the surgeon to work with." <table border="0" width="250" cellspacing="0" cellpadding="8" align="right" bgcolor="#D2E4C3"> <tbody> <tr align="center"> <td> <h3 style="margin-bottom: 0px;">Pediatric Prosthetic Launches Family Outreach Campaign</h3> </td> </tr> <tr> <td>Pediatric Prosthetics (Pink Sheets:PDPR), Houston, Texas, is pleased to announce the launch of its National Awareness Campaign to families affected by pediatric limb-loss. Kenneth Bean, vice president-operations, said, "Our efforts are now re-focused upon our core business-that of making the young families across the country aware of our commitment to their children. We have demonstrated that the news media in a given media market are very responsive to reporting the news of a child beginning a whole new future of running and playing with their friends, and we are going to build our outreach campaign on that premise. "We have contracted with a nationally known feature-article writing firm to tell our story, and to tell the stories of children beginning their new futures. The firm distributes feature articles to over 10,000 newspapers nationwide on a regular basis," he added. <img style="float: left;" src="https://opedge.com/Content/OldArticles/images/2006-05_02/f-2-4.gif" hspace="4" vspace="4" /> Bean continued, "We have already identified children in over 20 major media markets who need a properly fitted prosthesis, and we will be contacting their local television and newspaper people to share in the good news. We expect to continue to ramp up our monthly fitting rate steadily due to the outreach campaign."</td> </tr> </tbody> </table> Is there a risk of rejection with bone grafts? "That's debatable," Neel answers. "There are a certain amount of non-unions where the bone doesn't grow to the donor bone. We aren't sure whether that's a rejection phenomenon, or just a factor related to the difficulty of getting the patient's bone to grow onto grafted bone. The non-union rate is about 30 percent; children seem to do better at healing those junctions than adults, however." The REPIPHYSIS implant, also called a growing prosthesis, was welcomed into the St. Jude arsenal of innovative solutions in 1999, and Neel estimates that he and St. Jude colleagues Bhaskar Rao, MD, and Robert Heck, MD, have done 35 such implants since then, in order to help develop and perfect the original French-designed concept. "The old prostheses were just big chunks of metal mid-sections that needed to be replaced surgically as the child grew," Neel explains. "If you had a ten-year-old boy and took out the growth plate, the leg was not going to get any longer, but the other leg would. When he became 16, the prosthetic leg would be four to five inches shorter than the other leg. Replacing it with longer pieces every year meant multiple surgeries, risk of infection, time off from school, etc." The growing prosthesis replaces those multiple surgeries and all the negatives that accompany them, with a simple outpatient procedure that allows them to get up and walk out the same day. Neel estimates that about 40 surgeons around the US and 60 worldwide are using the expandable prosthesis in their pediatric patients, and the procedure continues to gain in popularity. <h4>Who Benefits?</h4> Which patients benefit most from the process? "Young patients suffering from primary bone tumors that involve the growth plate-primarily osteosarcoma and Ewing's sarcoma," Neel answers. "The majority of these tumors occur in the mid-teens, so there are only going to be a third of them who are skeletally immature and are thus candidates for the procedure. We have done patients as young as five. After about age 12 or 13 for girls, and 14 for boys, they don't get a lot of benefit from it, because they're almost skeletally mature." Although every new process includes a learning curve and some initial problems, says Neel, outcomes so far are looking good. Results reported at the 2005 meeting of the Musculoskeletal Tumor Society indicated that the average patient was able to avoid three surgeries by using the growing prosthesis. "I think within the next five years it will be pretty much generally accepted that even in a very young child, you can save the leg, keep the leg lengths equal till they reach skeletal maturity, and then convert them to a permanent prosthesis, whereas ten years ago, a significant portion of the people in the US would just do an amputation." Neel reports that "probably 95 to 98 percent of the patients that come through St. Jude can now get a limb salvage surgery." According to Wright Medical Technology, 90 hospitals in the country are now performing REPIPHYSIS implant procedure. That number includes Shriners Hospitals for Children in St. Louis, Missouri, where Douglas McDonald, MD, of the Washington University School of Medicine has recently begun utilizing the prosthesis. <table border="0" width="100%" cellspacing="0" cellpadding="8" align="right" bgcolor="#D4DCEE"> <tbody> <tr align="center"> <td> <h3 style="margin-bottom: 0px;">Company Creates "Special Needs" Dolls</h3> </td> </tr> <tr> <td><img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2006-05_02/f-2-5.gif" hspace="4" vspace="4" /> Sew Dolling" LLC, East Greenwich, Rhode Island, has launched a line of unique vinyl dolls used in play therapy that celebrates the differences and the challenges of special needs children. The company said the limited-edition Sew-Able-Dolls include nine with above-the-knee or below-the-knee amputations and three dolls without hair. Several years in the making, the dolls were produced and designed to look as real and natural as possible. "We believe the expense put into the doll is well worth it if it can help even one child, through play therapy, feel accepted," said Susan Svendsen, owner of Sew Dolling LLC. "This is also a great way to help other children who have friends, classmates, or siblings with disabilities understand that we are all different, special and unique!" The dolls with prosthetic legs have been specially fitted and include a pair of crutches. The dolls can stand with crutches and also can be positioned to stand without. A full line of physical therapy accessories is available, including wheelchairs, parallel bars, mats and therapy balls, allowing the child's doll to progress along with its owner. The dolls without hair come with a wig and a bandana, slouch hat, or baseball cap. "Play therapy is extremely important to help children build their sense of self worth," added Svendsen. "A child may long to meet or play with others who look like they do, but this is not always possible. These dolls are offered as a supplement to help a special needs child in their journey." The company said the limited-edition dolls have small production runs with some limited to just 172 in the edition and a portion of each sale is donated to hospitals that help special needs children. <i> For information, visit Sew Dolling on the web at <a href="https://opedge.com/577">www.sew-dolling.com</a></i></td> </tr> </tbody> </table> <br clear="all" /> <b><i>To locate a surgeon and facility currently performing the procedure in your area, contact Wright Medical Technology, 901.867.9971.</i></b> <b><i>Judith Philipps Otto is a freelance writer who also has assisted with marketing and public relations for various O&P industry clients. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.</i></b>
