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Medicine and Literature, Orthopedics, Patient Care, Pediatrics, Stanford News

From post-WWII Russia To 7-year-old Giana Brown, a limb-lengthening method evolves

From post-WWII Russia To 7-year-old Giana Brown, a limb-lengthening method evolves

young patientGiana Brown is one tough little girl. When she was 7 years old, an orthopedic surgeon, Jeffrey Young, MD, from Lucile Packard Children’s Hospital Stanford, placed a brace called a Taylor Spatial Frame on her lower left leg that would help lengthen it about three inches to match her right leg. To accomplish this, the brace would require adjustments of about one millimeter a day for more than six months.

Her parents could have made those adjustments, but Giana insisted on doing it herself. She used a little wrench to turn the knobs that would lengthen the struts on the brace according to a computer-generated, color-coded prescription sheet.

Sculpting Bones,” the story of Giana’s rare bone disorder, her surgery and her recovery, is featured in this summer’s edition of Stanford Medicine magazine. An animated graphic illustrates in detail how the brace and bone biology work together to lengthen limbs. The story focuses not only the remarkable method of cutting a bone and slowly lengthening the gap to allow it to grow — called “distraction osteogensis” — but also on the unusual history of the “external fixator” device that makes this growth possible.

The device originated in a remote region of Siberia, Russia, nearly 70 years ago, where a young doctor, Gavriil Ilizarov, MD, cared for a patient population that included soldiers returning from the front lines of World War II with a vast array of bone injuries. Ilizarov discovered his method of distraction osteogenesis by accident, and a revolutionary method of bone lengthening was born.

Several decades later, orthopedic surgeon Charles Taylor, MD, and his brother, engineer Harold Taylor, modernized the device, changing the angle of the struts for more flexibility, and creating a computer program that generated prescriptions, “accurate to within a millionth of an inch and a ten-thousandth of a degree,” for adjusting the struts daily.

Although Giana’s dad, Greg, accurately describes the device as “draconian-looking,” her surgeon, Young, hails it as an ideal tool for healing his pediatric patients. “I really like how the technology allows me to basically sculpt the bone,” he says. “It’s the perfect blend of engineering and art.”

For Giana Brown, the accuracy, simplicity, and artistry of the device has paid off: She’s back to running and playing with her friends the way a healthy, happy kid should. Read her story – and her tips for making life a little easier in the frame –  here.

Previously: Stanford Medicine magazine opens up the world of surgery
Photo of Giana Brown by Max Aguilera-Hellweg

Global Health, In the News, Orthopedics, Pediatrics, Stanford News

6-year-old Palestinian boy learning to walk after treatment at Lucile Packard Children's Hospital Stanford

6-year-old Palestinian boy learning to walk after treatment at Lucile Packard Children's Hospital Stanford

Hadi_mom_and_Richard_Gee-small fileHadi Alkhadra is a small boy with a huge grin. He’s got reason to smile: After living for years with a severe congenital defect that made it challenging to stand and impossible to walk, the 6-year-old Palestinian boy is on his feet. Last fall, Hadi and his mother came around the world from the Tulkarem refugee camp in the West Bank, Palestine to Lucile Packard Children’s Hospital Stanford so that he could receive several months of orthopedic surgeries and physical therapy.

The treatments address Hadi’s arthrogryposis, a condition that is analogous to polio in utero. Before he was born, some of the motor centers on Hadi’s spinal cord were damaged, probably by a virus. Some of the muscles that are supposed to move his knees, ankles and feet do not work normally. As a result, before treatment, his feet pointed backward and his knees had very restricted motion, bending only a small amount in the wrong direction. From the hospital’s press release about his journey:

With assistance from the Palestine Children’s Relief Fund, Hadi and mom Shireen have traveled 7,500 miles to receive care from orthopaedic surgeon Lawrence Rinsky, MD, who has led Hadi’s successful surgeries at Lucile Packard Children’s Hospital Stanford. Though there is no complete cure, with the assistance of braces and our Rehabilitation Services team, Hadi is now able to wear shoes for the first time, stand with his feet flat, leave his new wheelchair and start walking.

A warm, outgoing and intelligent young man, Hadi has become a big fan of the 49ers, Chuck E. Cheese, and iPads since arriving in the Bay Area last fall. Now, he looks forward to seeing his sister, two brothers and dad when he returns home in late June. Though he will wear lower-leg braces for most activities, including walking, for at least a few years, Hadi will be able to attend school for the first time while planning his dream “to be a surgeon, just like Dr. Rinsky.”

Previously: How orthopedic surgery straightened out one man’s life, Custom-made exoskeleton helps young girl with muscle disease use her arms and Strong-arm tactic: Saving toddler’s limb from amputation
Photo of Hadi with his mother, Shireen, and his physical therapist, Richard Gee, courtesy of Lucile Packard Children’s Hospital Stanford.

In the News, Orthopedics, Research, Sports

Helping to prevent ACL tears in young athletes

Helping to prevent ACL tears in young athletes

Luke RichessonA clinical report recently released by the American Academy of Pediatrics provides 14 recommendations for doctors who work with children in school or sports programs to reduce the risk of knee injuries such as anterior cruciate ligament (ACL) injuries, which are increasingly common in that demographic. A Reuters piece notes, “The ACL can tear when athletes quickly change direction, land on their leg incorrectly, stop suddenly or collide with each other” and that injury to this key knee-stabilizing ligament is especially common in college-aged women.

More from the article:

The report says neuromuscular training programs that strengthen leg muscles, improve stability and teach people how to safely move should be encouraged.

The authors write that the components of training programs that have effectively reduced the risk of ACL tears include plyometric or jump training and tailored feedback for individual athletes.

Programs that also include strength training have been among the most successful in reducing ACL injury rates, they add.

I connected with orthopedic surgeon Jason Dragoo, MD, head team physician for Stanford Football and a Stanford Athletics team physician, who said each day his clinic sees an average of four new ACL tears, approximately 25 percent of those in adolescents.

Dragoo noted that numerous programs for ACL prevention are being distributed in athletic programs, including those at Stanford. Working with the University’s strength and conditioning program and using research from the Human Performance Lab and methods such as the Oslo 11+ program, physicians and trainers integrate ACL-prevention exercises into athletes’ warm-up and conditioning routines, teaching the body to move with healthy alignment. “A lot of ACL tears occur during fatigue,” Dragoo said. “We’re training [athletes] to move correctly even when they’re tired.”

Previously: How much for those healthy knees?Exploring the use of yoga to improve the health and strength of bones and Researchers call for improvements to health screenings for female college athletes
Photo by ASSOCIATED PRESS

Chronic Disease, Orthopedics, Pain

Finding relief from lower back pain

lower back painIf you thought a pain in the neck was inconvenient, try on chronic lower back pain for size. (Just kidding – both sound uncomfortable.) In a recent article, Prevention magazine suggests easily administered treatments for the latter kind of pain. Tips include paying attention to your body by noticing if you pronate your feet, taking action by attending yoga classes, and winding down with massage or acupuncture sessions.

Recognizing that back pain’s sometimes intractable nature can cause stress in other forms, the piece continues:

No, the pain isn’t in your head. But what is in your head could be making it worse. “Fear, anxiety, and catastrophizing can amplify pain,” says [Stanford anesthesiologist Sean Mackey, MD, PhD]. “People often get swept up in thoughts like This will never get better.” Because brain circuits that process pain overlap dramatically with circuits involved with emotions, panic can translate into actual pain. Cognitive-behavioral therapy helps you recognize and reframe negative thoughts. Deep breathing can help, too, as can simply shining a light on dark thoughts. “Start by accepting that you have pain,” Mackey says. “Then say to yourself, It will get better.”

Previously: Stanford researchers address the complexities of chronic painExploring the mystery of painExploring the use of yoga to improve the health and strength of bones and Ask Stanford Med: Pain expert responds to questions on integrative medicine
Via @StanfordHosp
Photo by U.S. Army

Orthopedics, Technology

"Intelligent" liner may improve prosthetic limb fit and function

0984-FieldsRuns200.jpgWhen I lived in the triathlete town of San Diego and tagged along for fun with a group who trained, a kind young man always gave me an encouraging word or high-five as he zoomed past me while running or cove swimming. He has a prosthetic leg, and although the device that helps him move around was clearly functional, and even sounded springy on the pavement, I wondered if a small shift in alignment could cause a great deal of discomfort.

This thought came back today as I came across news about an “intelligent” liner for better-fitting prostheses. A prototype of the device, which is being developed by researchers at the University of Southampton, uses sensors to detect pressure and forces at the point of contact between a patient’s stump and the prosthesis. Information on limb loading could lead to a better fitting and perhaps self-adjusting prosthesis, according to a release, which also notes:

There are 50,000 lower-limb amputees in the UK, most of whom use artificial limbs that are attached to the residual limb through a socket. No two stumps are exactly the same shape and size and even an individual’s stump can change shape over the course of a single day.

Pain, discomfort and ulceration are frequently experienced at the socket interface due to poor fit. This stems from the excessive build-up of pressure within the limb socket (causing high ‘loads’ on the stump).

Synthetic liners, worn like a sock over the stump, provide some cushioning against the hard socket, but at present there is no convenient way to accurately measure the critical loads at this interface in the clinic. Without this information, prosthetists face difficulty in fitting replacement limbs and the outcomes for patients are variable.

According to the non-profit Amuptee Coalition, nearly two million people in the United States live with limb loss.

Previously: Stanford graduates partner with clinics in developing countries to test low-cost prostheticBiotech start-up builds artful artificial limbs and Two Stanford students’ $20 device to treat clubfoot in developing countries
Photo by U.S. Army

Medicine and Society, Orthopedics, Stanford News

Art and anatomy: Decades-old collaboration brings augmented reality into the hands of Rodin

Art and anatomy: Decades-old collaboration brings augmented reality into the hands of Rodin

This Wednesday, the Cantor Art Museum is launching a first-of-its-kind exhibit, “Inside Rodin’s Hands: Art, Technology, and Surgery.” This unique exhibit uses 21st Century technology to look inside the works of Rodin’s 19th Century sculptures.  As described by Tracie White in today’s Inside Stanford Medicine, the exhibit:

…is a feat of interdisciplinary collaboration that celebrates a long-time connection between sculptor Auguste Rodin’s fascination with the human form and medicine’s fascination with human anatomy.

“A deep and rich history unites the art of the museum with the medical school,” said Connie Wolf, museum director, which has one of the largest Rodin exhibits, with 200 of his sculptures, including the Thinker and the Gates of Hell. “These statues have inspired faculty at the School of Medicine. Art is informing medicine in this exhibit. It’s unlike anything we’ve ever done before.”

Indeed, the rich history that Wolf refers to goes back to the early 90’s when Albert Elsen, PhD, joined forces with Robert Chase, MD. Elsen, a leading authority on Rodin, was the person most responsible for amassing the museum’s huge collection. Chase, then head of the Division of Anatomy, knew his art, too, having taught a popular course on Renaissance art and anatomy.

Because Rodin was known to use models with diseases and deformities, these two “super docents” delighted in taking med students on strolls through the Rodin Sculpture Garden. They’d wend their way through the garden, from one statue to the next, prompting the students to determine whether there were actual clues belying a medical condition, or were they simply seeing the results of the sculpture’s artistic license?

In 1991, I was lucky enough to tag along on one of these walks. By that time, I’d logged scads of Saturdays and Sundays at the garden, usually with drawing pad in hand. This time, it was a very different kind of tour, more akin to doing rounds in the hospital. These works of art that were models for my drawings, were now being diagnosed like patients. I was fascinated from the get-go. The last stop on our tour was the Gates of Hell. After an introduction to the monumental bronze, the focus shifted to the final “patient,” the life-sized statue of Eve, positioned on the right-side of the Gates. She sparked the liveliest discussion of the tour: Was the model for Eve pregnant? If so, how far along might she have been?

I remember how excited I was, seeing Rodin’s art in an entirely new way. It never entered my mind, that decades down the road, I’d get to experience that newly enlightened excitement, again. Nor, did it occur to me that I’d get to witness the trajectory that spans the last 23 years.

Continue Reading »

Imaging, In the News, Orthopedics, Research

Goo inside bones provides structural support, study finds

Goo inside bones provides structural support, study finds

As high-schoolers swarm the med school campus today, hold human brains and satisfy their taste for science, I can’t help but wish the show “You Can’t Do That on Television” still existed and that the producers would set up in the parking lot and slime each participant upon completion of the day. But a welcome alternative is news that scientists have discovered gooey matter inside human bones.

In a 60-Second Health piece, writer Dina Fine Maron explains how “a combination of imaging techniques and modeling has revealed that our bones are filled with a natural chemical goo that’s key to the bones’ function as support structures,” and that the information could be used to inform osteoporosis treatment and prevention. The researchers’ findings were published in the Proceedings of the National Academy of Sciences.

Previously: Exploring the use of yoga to improve the health and strength of bones, 419 million year-old fish fossil may reveal origins of the human jaw and  Teen girls become orthopaedic surgeons for a day

Health and Fitness, In the News, Orthopedics, Stanford News

Watching your phone or tablet while working out may diminish form

Watching your phone or tablet while working out may diminish form

skeletonSnow White’s dwarves whistled while they worked. With the advent of the Walkman, runners could listen to music as they ran. Now, some people watch TV or movies on a mobile device while they hit the gym. Though all make a demanding physical task more entertaining, looking down at your smartphone in text-head position could harm your skeletal alignment, as Michael Fredericson, MD, professor of sports medicine at Stanford and team physician for several of the school’s sports teams, recently told the San Francisco Chronicle.

From the article:

Although [Frederickson’s] in favor of anything that gets people to exercise more, he warns that running while you look down at a screen is poor form, and the distraction prevents you from focusing on your body.

“When you lean forward, you create an arch and hyperextension in your neck,” he says. “You may get a good cardio workout, but when you get off, you’ll be stiff in your upper body.”

Listening to music while you exercise might be a better option. Unlike TV or streaming video, many studies show that music can benefit a workout by distracting people from fatigue and elevating mood.

Fredericson said he even encourages people in his community running clinic to align their running cadence with songs that have 90 beats per minute. But he adds that the most serious runners, like those he works with on the Stanford track team, don’t train with media distractions. “They’re very focused on their bodies and the experience,” he said. “They have a goal in mind for every workout.”

Previously: Walking-and-texting impairs posture – and walking, and texting
Photo by Jim, the Photographer

Orthopedics, Sports, Videos

Using motion-capture technology to identify movements that alter tissue in dancers

Using motion-capture technology to identify movements that alter tissue in dancers

In a marvelous duet between humans and technology, the late choreographer Merce Cunningham used motion-capture sensors on dancers’ bodies to record movement and project the electronic dance as visual design for his 1999 work BIPED. Now, computer scientist Nadia Magnenat-Thalmann, PhD, of the University of Geneva in Switzerland has used sensors to capture what happens to dancers’ internal tissues during the movements they perform day after day. She presented her animations at a recent American Association for the Advancement of Science conference.

As New Scientist recently reported:

[Magnenat-Thalmann’s] team carried out MRIs – but also asked six ballet dancers to perform typical dance moves while wearing a motion-capture suit. This allowed them to animate the underlying bone image with each dancer’s movements.

The result is a moving three-dimensional model of the ballerina’s skeleton – that mimics her actual movements. Algorithms then calculate how much stress is placed on each part of the body, drawing attention to areas that are likely to cause trouble in the future.

The findings could help doctors address joint problems and cartilage deformation among dancers. (And perhaps, one hopes, save a few from needing altogether-too-common hip replacements?)

Previously: Is repetitive heading in soccer a health hazard?Measuring the physical effects of yoga for seniorsWalking-and-texting impairs posture – and walking, and texting and Researchers look at brain activity to study falling

Orthopedics, Research

Walking-and-texting impairs posture – and walking, and texting

Walking-and-texting impairs posture - and walking, and texting

Figure 1My yoga teacher, Annie Carpenter, frequently includes movement directions in class that counteract a modern epidemic she calls “text head.” (Look down at your phone and notice your posture.) So I was delighted to come across a post today on PopSci.com highlighting a recent study on the very subject, citing many reasons you should bring your head into alignment with your spine right now.

Researchers from the University of Queensland, Australia used motion-capture technology to study how reading or typing with a mobile phone while walking affects the gait. The 26 participants walked in a straight line for approximately 8.5 meters.

PopSci reports that, “No surprise, the people reading or texting were slower, deviated from a straight line more, and on top of everything, didn’t text very accurately.”

From the study:

Gait performance was evaluated using a three-dimensional movement analysis system. In comparison with normal waking, when participants read or wrote text messages they walked with: greater absolute lateral foot position from one stride to the next; slower speed; greater rotation range of motion (ROM) of the head with respect to global space; the head held in a flexed position; more in-phase motion of the thorax and head in all planes, less motion between thorax and head (neck ROM); and more tightly organized coordination in lateral flexion and rotation directions. While writing text, participants walked slower, deviated more from a straight line and used less neck ROM than reading text. Although the arms and head moved with the thorax to reduce relative motion of the phone and facilitate reading and texting, movement of the head in global space increased and this could negatively impact the balance system.

The authors note, “Changes in gait associated with mobile phone use may undermine functional walking and impact on safety in common pedestrian environments.” So, keep your head up!

Previously: Toilets of the future, and the art of squatting, Exploring the use of yoga to improve the health and strength of bonesSpinal bracing for adolescents with scoliosis and “Barefoot” running craze still going strong
Photo by Schabrun et. al

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