Personalized Spinal Implants: Nikki’s Story

Four. That’s the number of days it took for Nikki Clark to return home following scoliosis surgery at CHOC Children’s Hospital. Dr. Afshin Aminian, an internationally-recognized expert in pediatric orthopaedics and medical director of the CHOC Children’s Orthopaedic Institute, performed the surgery using the latest techniques and technology to minimize pain and yield the best outcome for his teen patient.

A customized approach to care

Nikki was among the first patients at CHOC to benefit from personalized spinal implants. Based on detailed measurements and perioperative planning, customized rods were created to the precise length and shape of Nikki’s spine. The goals of this approach are better alignment and accurate correction of the patient’s spine. Customized implants and patient-specific rods decrease surgical time. In addition, they have the potential to improve recovery time and minimize future problems related to scoliosis.

scoliosis surgery
X-rays of Nikki’s spine, before and after receiving custom spine implants during scoliosis surgery.

“Our specialists have fine-tuned the most innovative, effective treatments for scoliosis, with a focus on maximizing each patient’s ability to function, grow and enjoy quality of life,” says Dr. Aminian. “Most of our patients are active teens, who are eager to return to their sports and activities. We want to do everything we can to help them do that.”

Making the jump

A swimmer and competitive water polo player, Nikki was thrilled to hear Dr. Aminian’s approach to care. Less than a year after being diagnosed, she decided to pursue surgery rather than wait. Her focus:  being ready for the upcoming season.

“I knew my life was going to get busy and really wanted to make sure I could play water polo during my junior and senior years. I wasn’t afraid of the surgery or the pain. I was more worried about not being able to play,” explains Nikki.

The morning of her surgery, Nikki began feeling anxious; not scared, as she pointed out to the child life specialist who came to check on her in pre-op. “I knew I had the best doctor, at the best hospital in California, and was ready to get the surgery over and done,” recalls Nikki.

A few hours after surgery, Nikki was surprised she wasn’t experiencing as much pain as she anticipated. The next day, a physical therapist helped her sit up for the first time. “It felt so good to finally be able to move,” says Nikki, who also enjoyed ordering milk shakes from CHOC’s room service menu. The chocolate banana one was her favorite.

scoliosis surgery
After scoliosis surgery to receive personalized spinal implants, Nikki was surprised she wasn’t experiencing as much pain as she anticipated.

She continued to follow all the guidelines, including getting out of bed to walk. Her physical therapist and nurses were among her biggest cheerleaders, praising her for quickly reaching the milestones required for her to go home. On Nikki’s fourth day at CHOC, Dr. Aminian proudly announced she was going home.

Nikki’s recovery at home continued to progress at a record pace. A month later, she returned to school. Two months later, she was back as a junior life guard in Newport Beach. The determined athlete surprised everyone by finishing the “monster mile,” which includes running a mile and swimming a mile. By the end of summer, she had also completed eight jumps off the pier.

scoliosis surgery
Nikki loves being outdoors, and quickly returned to her active lifestyle after scoliosis surgery.

Back in competitive water polo, Nikki proudly shows off her surgical scar. She’s been approached by other players, who have scoliosis. She encourages them to “make the jump.”  “You’re strong and in great shape. You can handle surgery,” she tells them.

Learn about scoliosis services at CHOC now.

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Return to Learn Concussion Guidelines Every Parent Should Know

When a child has a concussion, the rules for getting back to sports are laid out by state Return to Play laws. But when it comes to getting back to the classroom, the rules aren’t as clear.

A recent study in the journal Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in terms of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.

“When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms,” explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s. “While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.

return to learn
Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.

“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”

Dr. Koutures advises the patient’s care team, including parents, to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:

Step-wise Return to Learn Progression

Step 1: No formal academic activity

  • Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
  • In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
    • Listen to light music
    • Draw or color
    • Journal writing
    • Audiobooks
    • Passive television or movies (at home), larger screen preferred, lower volume
    • Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
    • Conversations with 1-2 other people
  • Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
  • If symptoms flare before 15-20 minute limit, stop activity and try again later
  • If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school

Step 2: Light academic activity

  • Attend 1-2 periods or 1-2 hours of school
  • Select consecutive classes; have child help make decision
  • No physical education or other activity classes
    • Caution with more noisy classes such as woodshop, music/band, chorus
  • Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
  • Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
    • Audible learning (most kids handle this better than visual learning after a concussion)
    • Should have pre-printed notes for reference or have others take notes and share
  • Sit away from louder students, windows, projectors, or other light/noise stimulation
  • Sit close to teacher
  • Allow to wear earplugs and sunglasses as needed
  • May allow brief 1-2 minute periods of putting head on desk for rest
  • May leave class early to avoid the noise and commotion of hallways during passing periods

Step 3: Increased academic activity

  • Expand day to 3-4 periods or hours per day
  • Incorporate break periods (nutrition break, lunch)
    • Have quiet place to rest
  • Recommend against assemblies or rallies due to noise stimulation
  • Continue to avoid physical education or activity classes
  • Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework

Step 4: Full-time attendance

  • Full-day attendance without activity or other higher-stimulation classes
  • May expect some increased fatigue at end of school day
    • If student wants to nap after school, limit to no more than one hour
  • May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
  • Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
  • Break period and breaks in class (especially if block schedule) may still be needed
  • If possible, move most challenging courses to time of day when student feels the best

Step 5: Return to Majority of Academic Activities

  • Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
  • May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
    • Waive any projects, papers, essays or other assignments that are not required for future learning needs
    • Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
      • Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
    • No tests or quizzes at this stage
    • Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point

Step 6: Return to Full Academic Activity

  • Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
  • Can resume tests and quizzes
    • Strongly consider waiving missed tests or quizzes
    • Combine missed tests or quizzes to allow more quick completion of make-up work
    • Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
    • Assign grades at end of grading period based on level of work prior to concussion
  • May need more time for test completion
  • May need individual room placement for testing
  • May limit testing/make-up testing to one test per day
  • May allow open book, use of notes, word banks or home-based testing
  • Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
  • Students may still benefit from more audio learning
  • Can resume physical education (with physician release) and activity courses
Learn about the CHOC Children’s Concussion Program now.

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Nursemaid’s Elbow in Kids Caused by Common Activities

Nursemaid’s elbow is one of the most common injuries in small children, and it can happen during the most innocent activities, like swinging a child by the arms or playing tug-of-war.

“There is a natural looseness in the ligaments of little kids’ elbows,” according to CHOC Children’s pediatric orthopaedic surgeon Dr. Jessica McMichael. “Nursemaid’s elbow happens when the arm gets tugged or pulled, which can partially dislocate the radial head portion of the elbow.”

The injury can happen when a baby or small child is lifted by the hands, or when a child tugs their arm while holding someone’s hand. It can also happen when an object is pulled from their hand, when a baby rolls over or because of a fall.

What are Symptoms of Nursemaid’s Elbow?

Parents can look for these characteristic signs of nursemaid’s elbow in their child:

  • The child stops using their arm normally or treats their arm gingerly
  • The elbow appears straight and the child doesn’t want to bend it
  • The child holds their arm limply and away from the body, “like a paralyzed arm”
  • The palm is rotated inward, rather than facing out toward the front of the body
  • The child complains of pain in the elbow, forearm or wrist
  • Someone holding the child’s hand may feel a pop in the child’s wrist when the injury happens

Nursemaid’s elbow is a very common orthopaedic condition treated at CHOC, according to Dr. McMichael. It is likely to happen multiple times after a child has it once.

“Nursemaid’s elbow is not threatening to the limb, but it does need to be treated,” Dr. McMichael says. “It’s okay to wait until the next morning if your child is acting okay. If your child is not acting like themselves, get it checked out.”

How to Fix Nursemaid’s Elbow

To fix nursemaid’s elbow, a medical professional will gently and quickly pop the elbow back in place. A child might feel pain for a brief moment during the procedure but should start using their arm normally within a few minutes.

If a child’s elbow pops out of place three or more times in a month, a cast may be put on to immobilize the arm and promote stiffness.

Nursemaid’s elbow can be treated by a pediatrician, a pediatric orthopaedic specialist or at a pediatric emergency department. Parents should not correct the elbow themselves unless instructed by a doctor.

Dr. McMichael encourages parents to educate people who are around their child, like grandparents, daycare staff and preschool teachers, about the safest ways to lift a child, hold their hands and play with them.

Nursemaid’s elbow is less likely to occur after age four, when the elbow ligament starts to tighten up and improves with age and growth.

To make an appointment with a CHOC orthopaedic specialist, call 888-770-2462.

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How to Boost Your Child’s Bone Health

Physical activity, calcium and vitamin D are essential for building strong bones, says Dr. Samuel Rosenfeld, orthopaedic surgeon with the CHOC Children’s Orthopaedic Institute. Developing good bone health during childhood helps prevent fractures and osteoporosis later in life.

bone health for kids
Dr. Samuel Rosenfeld, an orthopaedic surgeon at CHOC Children’s, offers tips on how to boost bone health for kids.

Bone is living tissue in the skeleton that constantly changes. Old bone gets replaced with new. The greatest amount of bone tissue grows during childhood and adolescence as the skeleton expands in size and density. It is during this period of active growth when calcium is essential. In addition to requiring a great deal of calcium, the young body absorbs calcium more effectively. For this reason, children need to “bank” extra calcium for bone health.

Some of the most common sources of calcium are from dairy products, such as milk, yogurt and cheese. Note, however, that calcium in dairy products are bound by fat and not absorbed. For that reason, children should get their dietary calcium from fat-free dairy products taken at least one hour away from meals. Other sources include calcium-fortified soy milk and juices, canned salmon (with bones) and sardines, and dark green, leafy vegetables, such as broccoli and kale.

For calcium to be effective in bone growth and development, it is also important that children get enough vitamin D. This can be done through careful sun exposure and eating vitamin D-rich foods such as fortified milk and milk products, cod liver oil, red meat, eggs, mushrooms and some fatty fish.

Calcium and vitamin-D supplements are also important to consider, to ensure children, especially those with certain chronic conditions, are getting enough bone-boosting nutrients. Parents should consult their child’s physician before giving supplements. In this video, Dr. Rosenfeld explains that building healthy bones actually starts while the child is still in the womb, and continues through childhood. Below are Dr. Rosenfeld’s general recommendations:

Age 7 and younger

Calcium intake: 250 mg twice daily

Vitamin D3 intake: 250 IUs twice daily

Ages 8-13

Calcium intake: 500 mg twice daily

Vitamin D3 intake: 500 IUs twice daily

Age 14 and older

Calcium intake: 600 mg twice daily

Vitamin D3 intake: 2000 IUs twice daily

In addition to a calcium and vitamin D-rich diet, children should participate in physical activity, advises Dr. Rosenfeld.

“Ideally, exercise should be part of a child’s daily routine. Parents should help their children find activities and sports they enjoy, so they’ll continue to participate in them,” says Dr. Rosenfeld.

Good bone health is not difficult to achieve and maintain, adds Dr. Rosenfeld.

“It doesn’t take fad pills or fancy supplements,” he explains.
“Establishing a routine of taking calcium and vitamin D, along with a little exercise, is the ‘prescription’ for healthy bones.”

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Meet Dr. Francois Lalonde

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Francois Lalonde, a board certified pediatric orthopaedic surgeon.

Dr. Francis Lalonde
Meet Dr. Francois Lalonde, a board certified pediatric orthopaedic surgeon at CHOC Children’s.

Q: What is your education and training?

A: I attended medical school at University of Toronto School of Medicine. I completed my orthopaedic surgery residency at the University of Ottowa, and a pediatric internship at Montreal Children’s Hospital/McGill University. I completed a pediatric orthopaedic surgery fellowship at both Children’s Hospital of Eastern Ontario/University of Ottawa, and San Diego Children’s Hospital and Health Center/University of California San Diego.

Q: What are your current administrative appointments?

A: I am president of the CHOC Orange medical staff; medical director of the hip program, CHOC Orthopaedic Institute, member of the CHOC board; and president of Adult & Pediatric Orthopaedic Surgery medical group.

Q: How long have you been on staff at CHOC?

A: 11 years.

Q: What are your special clinical interests?

A: My clinical interests include infant, child, adolescent and young adult hip conditions (DDH, Perthes, SCFE, impingement); pediatric fractures and musculoskeletal injuries; pediatric foot conditions and reconstructive surgery; general pediatric orthopaedic conditions; limb lengthening; surgical treatment of bone deformity in osteogenesis imperfecta; and cerebral palsy.

Q: What are your most common diagnoses?

A: We see a variety of conditions, including forearm and elbow fractures; developmental dislocation of the hip in infants; Perthes disease; slipped capital femoral epiphysis (SCFE) condition of the hip; joint, extremity pain in children, adolescents (overuse, growth related); idiopathic adolescent scoliosis; among others.

Q: Are you working on any current research?

A: Yes, on Legg-Calve-Perthes research. We are looking at our five year experience with patients treated with open hip adductor lengthening, range of motion, nighttime orthosis and limited weight bearing protocol. Our patients have maintained femoral head sphericity and containment with congruent hip joint with very limited surgery. Many patients have been back to sports without any symptoms.

Q: What are some new programs or developments within your specialty?

A: Orthopaedic surgeons are better able to diagnose hip impingement based on radiographic and imaging assessment and depending on severity of underlying findings or condition, treat this condition with arthroscopy or surgical hip dislocation with femoral head/neck osteochondroplasty and/or acetabular rim trimming. In doing so, we are better able to differ the onset of premature degenerative changes (arthritis) of the hip.

Advanced hip joint preservation surgical techniques such as the Ganz periacetabular ostetomy and relative femoral neck lengthening have emerged to treat the sequelae of developmental dysplasia of the hip and other childhood conditions. In the appropriate setting, these surgical techniques are able to relieve hip pain and significantly delay or prevent the onset of premature degenerative changes (arthritis) of the hip.

A modular magnetic intramedullary nail (Precise nail) is now available to allow orthopaedic surgeons to lengthen the femur or tibia by up to 8 cm in patients with moderate or large limb length inequality. This internal device is being better tolerated by patients with less soft tissue irritation.

In addition, for several years now, the Fassier-Duval telescoping intramedullary nail has been used at CHOC to correct severe deformities of the femur and/or tibia in patients with osteogenesis imperfecta. This modular implant which is anchored at the top and bottom telescopes as the bone grows and has helped avoid multiple revision surgeries in childhood due to migration of the implant and refracture.

Q: What would you most like community providers to know about your division at CHOC?

A: Our division covers the entire spectrum of subspecialties in pediatric orthopaedics (fractures, upper extremity, spine, hip, lower extremity, sports medicine, foot/ankle, bone tumours, neurosmuscular conditions – cerebral palsy, spina bifida, muscle disease, osteogenesis imperfecta, brachial plexus injury, concussion). We have three offices in Orange, Irvine and Mission Viejo, in addition to the CHOC Clinic. We try to see our referral patients promptly, and are accessible by phone for questions from physicians.

Q: What inspires you most about the care being delivered at CHOC?

A: I’m inspired by the expertise, drive and dedication of our physicians, nurses and support staff, as well as our state-of-the-art facility, the wide range of subspecialists within pediatrics, the emphasis on patient safety and experience, and the emphasis on delivering high-level quality care to our patients.

Q: Why did you decide to become an orthopaedic surgeon? 

A: I decided to become a doctor as a teenager. I had a part-time job as a lifeguard at local pools and beaches in Ottawa, Canada, in which I was required to take first aid courses, and that piqued my interest. Later, while attending university, I worked as a children’s swim instructor and gained interest in pediatrics and pediatric orthopaedics. I became interested in orthopaedic surgery as a medical student during a pediatric orthopaedic surgery rotation when I was exposed to a great role model.

In addition, my uncle, who is an obstetrician and gynecologist, was an early role model. I often listened to him talk about his work and schedule during the summer. I used to spend the entire summer at my parents’ cottage in the Laurentians in Quebec, Canada. My uncle’s cottage was right next door. I liked the diversity of his daily routine. His days were busy either seeing patients in his office for initial consultation or follow-up, or performing surgeries or delivering babies.

Q: If you weren’t a physician, what would you be and why?

A: I would have become a marine biologist. I became interested in this field by watching documentaries, taking biology classes, and by scuba diving.

Q: What are your hobbies/interests outside of work?

A: I enjoy playing ice hockey, as well as watching or attending all sports events.

Q: What have you learned from your patients?

A: I have learned that making funny noises when I examine babies’ hips really distracts them and elicits a smile and lets me conduct my exam more effectively and reliably. With older kids, I have learned how challenging it is to treat great athletes, who present with joint or extremity pain often from overuse, and they can find it difficult to commit to a period of rest, which is often necessary to allow for recovery.

Q: What was the funniest thing a patient told you? 

A: One of my patients keeps asking me, “Where is your gold tie?” The first time he met me I was wearing a gold tie. Every time he sees me now, he asks me about my gold tie. I keep asking him to call me the day before so that I can wear it on the day he comes but he keeps forgetting to call.

Watch a short video to learn more on Legg-Calvé-Perthes disease

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