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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

Pediatric orthopedics differs from adult orthopedics because it must account for growing bones, growing joints, and growing muscles which behave very differently than those of adults.

We're going to talk about the treatments and scoliosis, also hip disorders and foot disorders and some complexities that come with both of those.

This evening's program is underwritten by the El Paso Children's Hospital, and we also want to say thank you to the El Paso County Medical Society for bringing this program to you for over 28 years.

I'm Kathrin Berg, and this is the El Paso Physician.

Neither the El Paso County Medical Society, its members, nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Thanks for joining us.

We are going to be talking about pediatric orthopedic surgery today.

And we are with El Paso Children's Hospital.

And there are orthopedics all over the place.

We get that.

And before the program we were talking about pediatric orthopedics is a very finite specialty because there's a lot of growing things happening within the bones.

And you can't just go in repair without having the idea of growth plates and everything else involved in that.

So we have two individuals with us.

And thank you so much for coming to El Paso.

Number one, we have Doctor Marcella Woiczik, And, Doctor Marcella says people just don't even say Woiczik And it's the beautiful spelling of W O I C Z I K So I am going to honor you all night long and call you doctor Woiczik because it's a thing.

She is a board certified orthopedic surgeon and hip specialist.

And again, pediatric special.

And she's with Texas Tech Physicians of El Paso.

And then we have Doctor John Heflin, who is also a board certified pediatric orthopedic surgeon.

And he specialize in spines.

So this is going to be great.

I, we've been doing this show for years, and I sit crooked, I walk crooked, I am a scoliosis girl, so I am looking forward to learning a lot from you all this evening.

Now that we've introduced you, I would love for you to take just a couple of minutes and tell us.

And, Doctor Heflin, we're going to start with you because Doctor Woiczik just said, you know, this is not something that I do and I'm good at doing.

Let me break the news to you.

No one's good at doing this.

And being on TV is not fun because it's just it makes you nervous.

So please know that all of us are in that same boat.

And because you didn't say you were nervous, you get to go first in that.

Great.

So, tell us why you came to El Paso and also with you specializing in pediatric spine surgeries.

Tell us what it is that you do all day, every day and Doctor Woiczik, we're going to do the same thing with you in just a moment.

So it's your floor.

Great.

Okay.

Well, we'll talk about what I do.

How about that?

They'll make it a little easier to understand why I came here in the first place.

Okay, so I take care of children.

Just like Woiczik.

We focus in a little bit different areas.

We both take care of common everyday stuff.

Fractures, lumps and bumps, sprains and, that sort of thing.

I have a focus in spinal disorders, so that would include, deformity of the spine, which would be like scoliosis and kyphosis, but also in, instability issues like Spondylolisthesis.

We were talking about mouthful.

That's now.

But spinal fractures, back pain.

So basically anything involved in that in the spine.

Okay.

And I've been doing spine specific work now for about ten years.

And what brought me to El Paso was, was, the understanding that the, the spine coverage was, was going to go away with, with the retirement of some of the, the local physicians.

Is it everybody has a career and everybody in their career ultimately.

And so, in, in looking around the country at, different opportunities.

And we'll get back to what that means here in a second.

El Paso came up as a possibility via one of our previous, trainees from from my program, the University of Utah.

We had trained, a person there, and they had come down here and had take and, established a practice here.

And, we had been in contact and it came up that there was, there was possibility of, of the, need, and the need was apparently, pretty great or forecasted to be and it seemed like a good opportunity to come down and provide something to the community that it, might have had but would be losing in the near future.

And so that's that's kind of how I got here.

I, started at, my, my started my orthopedic career, really at the University of Utah.

That's where I've been for the last, many years.

And for many reasons, it was time to move on to a different opportunity.

And, and this presented itself.

And so, that's how I, how I got here.

We really know why it is, is that there's no place like El Paso for Mexican food.

And I think many doctors move here because of that.

Could that be one of the reasons?

That's it.

And and also the fact I think tequila was developed here.

Tequila was developed here.

Exactly.

We need to take you to the El Paso del Norte.

There are so many reasons, you know but I'm I'm glad to hear that because.

And that is something too, that we, we joke about it, but at the same time, El Paso is such a community that you don't respect or know about until you actually get here and live here for a little bit, and then you're like, wow, this place is great.

We had actually had some involvement with El Paso, with outreach through Shriners program, years ago.

And, so we had been down here before Marcella, much more than myself.

But we knew a little bit about the town and the friendliness of the people.

And, and so we were at least somewhat aware of what we were getting ourselves into.

Yeah.

So what a perfect transition, Doctor Woiczik.

How do you do?

So what brought you here?

So you've been here a couple of times before, and kind of lead that same that same line of question.

So I think I'll start a little bit more with background.

Okay.

I started my job in pediatric orthopedics in 2007.

So I did my training up in Utah, and my training was combined at the University of Utah and Shriners Hospital for children.

In my role there, we would come to El Paso and cross over into Juarez, for my first ten years in practice, we did that four times a year.

Four times a year.

Nice.

Thank you for doing that.

And it was one of the highlights of my career.

It was, we transitioned to seeing patients in El Paso solely a couple of years ago, I think, when the climate changed a little bit socially.

And then we started seeing patients, just in a clinic nearby.

And, our interaction with the community was really, eye opening.

And, I think really just enjoyable for me in a different way than taking care of patients in an everyday clinic.

The patients that we took care of were incredibly grateful, didn't have great access for care.

And, we really lost a little bit of that interaction when Covid happened and we stopped being able to come down the way we used to.

And many other things changed with our practices where we were, where it was less of a community feel.

It was a little bit more cutthroat academic environment.

And so as lives have changed and people have changed their focus, I think even since Covid, the things that have become important are working with people that are a team and working with people who want to take care of each other and take care of the people in their community, which isn't something I had in my last job.

So, we, we were looking for opportunities.

We both have worked together for a number of years.

But there's a, surgeon here in town, Esteban Garcia, who, I had the opportunity to train when he was a resident with me and a fellow with me, and, he, he is someone who's been here in the community for many, many years.

And he said, we'd really like to help grow the pediatric orthopedic climate here.

There's been a couple of fabulous surgeons here that have been around for a long time.

And I think at some point they will end their career.

And this allowed us the opportunity to bring a little bit of youngness to it and, a little bit of, more comprehensive nature to the, to the community.

I've been in practice now for 18 years, and, I have a certain skill set.

John has a certain skill set.

Our other partner, Esteban, has a certain skill set.

We have two nurse practitioners that we're now working with and and we have a new, I think, enriched team that is really excited to work together and grow something.

And, just in the few weeks I've been here, the community is incredibly grateful in a way that I haven't had an opportunity to experience in years.

There there is no one like in El Paso when you know, there there is just, a way that just being here just invites gratitude, invites warmness, invites family.

Thank you so much for for coming to El Paso.

We appreciate that very much.

And I and I hope that you fall in love with the city as much as I have.

We were talking about a team earlier, and you said that you have about five people right now on your team.

That brings a team approach.

I volunteer for this program.

I work with the El Paso Community Foundation, and just yesterday we had UNICEF here.

El Paso, America's not really UNICEF happy but we are trying to bring specialties of pediatric medicine to El Paso.

Right now, the pediatricians are at a good number just because we're having less and less babies.

How are we don't have a lot of pediatric specialists.

So praising adoration to El Paso Children's for doing that and bringing you all in and for helping our community.

So I just wanted to put out there that first.

Doctor Heflin, I would I would like to talk about something that we hear a lot about, which is scoliosis.

And, if anyone's and I don't know if they do it, boys, but I remember when we were kids in school and right around the time when you'd start menstruating, everybody would go to the nurse's office and you'd you'd bend over in front of her, and they feel your spine and some kids got set to one side, some other.

And I was one of the ones that were set aside.

My I have a nice crooked spine.

But talk about scoliosis.

How common is it?

But then how and when is it, an issue enough to get some kind of treatment for it?

And I think that's probably where I'm going.

Like, where is it?

Like I haven't ever had treatment as I age, I my collarbones are not even I, you know, there's a lot of things going on, but it's never been it's chronic but benign.

And maybe explain where that becomes not benign anymore.

Sure.

Well, I mean, I think you have to understand what, scoliosis is to understand, you know, what we've been talking about, really.

For most of my medical colleagues, you'll know, scoliosis, is represented by a picture on an x ray where the spine is.

crooked, right.

I think what most people don't recognize is that scoliosis is actually a three plane deformity, where the spine, the traditional curve that you see in the spine is, is what we call the coronal plane.

Is just one part of the actual deformity in which the spine is actually producing a helix.

And so if you look at the spine from the side, it looks like this.

If you look at it from the front straight.

But what's happening is spine is twisting as you grow.

And so it's really a helical deformity.

That, that we're looking at in this X-rays that we take are really just, an estimation of how much that curve is changing over time.

So, so scoliosis itself is relatively common.

It's, it varies across the world.

And it's, certainly more common in girls than boys, for small curves, it shows up in, 1 or 2% of the population.

It's, about twice as common in girls, as boys.

As the curves get larger, they become more common in girls.

So curves in the 25 30 degree range end up being four times more in common girls, and then, So why is that?

No one really knows.

Okay, it's probably has something to do with the, rate of growth and the hormone milieu that, that girls have that boys, don't.

But no one really knows.

But what we do know about scoliosis is that the bones themselves, should go straight, right?

Most of our bones do.

There are bones that don't.

The femur doesn't go straight.

It twists.

Tibia twist, the humerus twists.

But the spine bones are not supposed to twist.

They're supposed to go straight.

But if you think of each one of these little spine bones as as, like a little tuna can, the lids are going in different directions as it grows at each level, and so what people mistake as a soft tissue disorder, they're like, well, I can send to the chiropractor and try to stretch out the muscles.

It doesn't work because fundamentally it's the bones that are having a problem, as is most of what we do.

You know, it's a they're bone related issues.

So, as the bones, twist as they grow, then the patient develops this helical deformity that we're talking about, which is why you see a red prominence, because then the as the spine twists, it twists up the chest, it twists and pushes up on the chest wall.

And so what you see what manifest when you do the Adams Fort Bend test.

If you're talking about is is a rib prominent.

And so small curves don't matter.

Right.

And that's the question.

So a 0 to 10 degree curve isn't even a curve.

We don't call it scoliosis.

Once you hit 11 degrees.

The Scoliosis Research Society has defined that as scoliosis.

And so from 11 to 25 degrees or so that's considered a small curve.

Small curves by and large are not problematic.

And, if you, graduate from adolescence with a 25 degree curve, no problem.

Let me just fine.

You can live your whole life for the 25 degree curve.

The back, tolerate small curves very well.

I mean, we have no natural curves that you see, right.

That are more than 25 degrees in most cases, curves between 26 and 45 degrees are considered a moderate size curve.

And those curves, are at risk of continuing to progress over the course of your lifetime, but typically not enough to warrant surgical intervention or stabilization.

Curves greater than about 45 degrees, have a tendency to progress throughout the course your lifetime.

Likely, just due to gravity.

And what are the issues that come with 45 plus?

I mean, what kind of conditions issues, aches, pains.

And so, curves over 45 degrees.

Don't necessarily have to have, an issue associated with them, but there is at least, an increased risk of more rapid progression over the course of your lifetime.

The larger the curve is at the time that you, stop growing, the faster that curve will progress.

And so curves of 55 degrees or so are thought to progress at somewhere between and a half a degree and a degree per year every year, which is very difficult to measure from year to year.

Yeah.

But 30 years down the road, you know, a 55 degree curve, maybe an 85 degree curve that is problematic.

And so curves around 90 degrees or so are, known to have physiologic consequences.

So an increased risk of restrictive lung disease and pneumonias and things as you get to be older, there is an association with back pain.

Once you get the curves greater than about 35 degrees or so.

And so the larger the curve is, the more likely you are to have, back pain.

And some of the curves can be somewhat debilitating in there.

So if we can explain to the audience and you're talking about, heart issues, for example, where is the spine play with having a heart issue?

Is it the way that, the spine is then coming into the cavity of the body or the twist that if it gets really big, it can it can cause, cardiovascular problems.

The biggest problem that that spinal deformity, causes really is, pulmonary problems.

So for respiratory type stuff and so effectively what's happening is it's twisting the actual box that the lungs live in and making them smaller.

But in addition to making them smaller, it's also making it stiffer.

And so you get a combination of, of restrictive type component where the, where the, the cavity that's available for lung expansion is small.

But on top of that it doesn't move very well either.

Okay.

And so the bigger that that deformity gets more problematic, that becomes.

And so as you get into very, very large curves, you know, 90 degrees, 100 degrees or whatever, you can have a very significant, restrictive type lung disease.

So when does a Doctor Heflin come in and give some treatment?

So I don't know if there's treatments other than surgically going in.

I remember, when I was in school, there was a girl that were a brace, you know, her curvature.

And I didn't know if that was again.

I'm looking junior high.

I'm thinking from ten years old to 14 years old.

And that's when growth spurts happen a lot with, with females.

And we always were kind of, you know, we thought it was just so exotic, like, okay, so what's happening?

When do you manipulate the spine in whatever way you need to?

So I tell people that, the management of scoliosis, comes in three flavors.

One is observation, which is the vast majority of what we do.

So small curves, we just watch, and, they can be watched all the way through adolescence.

And so, any curve below 25 degrees, we generally are just keeping an eye on for the most part.

If the patient is is younger, we do consider the second form of treatment, which would be bracing, which is what you just discussed.

There's many types of braces out there that that we utilize, in bracing protocols or moving target.

They, they have been forever, you know, we think we understand them until we really look at it and we don't.

So, the, the there's a fairly comprehensive study done looking at bracing and how effective it is that was done about ten years ago, actually.

And it turns out that, with a well made brace in a, in a child who has a curve between 25 and 45 degrees, there's about a 75% chance of keeping them out of the O.R.

if you if you brace appropriately, appropriately is 18 hours of wear per day.

It's a lot of weight.

Yeah.

And the ages, can you talk about when that would start?

Yeah.

And so the ages, in general are right at the beginning of adolescence.

So for the most part, kids in the 11 12 year old range up to about skeletal maturity, which would be about 14, 15 years of age.

So that's when you see most of the braces go on.

And we brace the younger kids in that who show up with early onset scoliosis.

And, we don't brace for kids older than that because it doesn't make sense.

You know, scoliosis, if it's a growth related phenomenon, you don't want to be bracing somebody 18 years old because they're not growing.

So if somebody is putting a brace on a child to 17, they're probably wasting everybody's time.

And so and so we you know, we do utilize bracing there.

There are curves that are too big.

There are curves that are too small.

But recently, bracing protocols are now, putting braces on children who have curves in the teens.

So 15, 16, 18 degrees, using a brace that they wear at nighttime, only just bending brace against with you.

And that's relatively new.

We haven't been doing that routinely for a while.

Day bracing generally doesn't start until you get into the 25 degree range or so, which is probably what you're familiar with.

And then when you hit about 45 degrees, we've, we've kind of all decided that bracing beyond that isn't going to save you from surgery.

It might slow your progression so that the curve isn't as bad when you finally get surgery.

Right.

So we still use braces, to try to kick the can down the road, so to speak.

But, but even when bracing is done absolutely perfectly.

Kid wears it 18 hours a day.

There's still, a 25, 30% chance that it's going to progress to surgery anyway.

So there's the next question.

So now we're at a point where someone who is, let's say 18, 19, where they're growing is is done.

And you, you people in your position say, okay, let's try to do surgery to correct the spine.

So physiologically, and we can, we can use this guy.

We were joking about trying to name him earlier.

Just a nod to, who used to call her spine guy, Doctor Bonaparte or Mr.

Bonaparte.

But in general, when we're looking at the spine, you're talking about the twisting surgically.

How would you go in and fix that?

And I know there's twisting in different areas of the spine.

So the the most common twist that you'll see in the spine is, is actually in the thoracic spine.

So this is, this is a spine model that shows the lumbar section down here which is five segments.

You've got your thoracic segment just 12, cervical up here.

Now you're looking at the patient back to front right.

So this is the back looking this way.

This is same way I look at the back in surgery.

The spine generally twists to this side like this through this thoracic spine much like this.

And so it's a twist to the side.

And this is you know what what leads to sort of the rib prominence.

The reality is actually can twist like this, but it's, it's kind of hard to recreate.

But anyways, it goes this way, but twist turns this way.

So the ribs are coming out.

The goal of surgery is to try to not only correct it in this in in this plane right here, but to also, you know, create a normal roundness to the back of a normal kyphosis, but also to rotate the spine, to try to achieve a neutral rotation of the vertebral body.

So it's actually a really complex, reduction that we're trying to achieve because we're trying to correct a three plane deformity.

The way that's done is you you essentially open the soft tissue so that you can see the back bones, and then we place, screws into each of the bones so that we can control each bone, that we're trying to, to correct.

We don't want to fuze the entire spine because then it's very, very stiff and can't move very well.

So we try to, selectively fuze as as little as we can to actually correct the deformity.

And then, but then prevent, progression above or below.

Right.

You got to be a little bit careful about fuzing too small because then you can end up with progression above or below the, the screws replaced through these, these little columns of bone right here called petals, hence the name pedicle screw.

So the screws will go into each of the vertebral bodies that we want to try to control.

And then we bend our rods to, to look like the shape that we want the spine to be at the end of the case, sort of.

And we, we do use some fancy bending to try to account for the deformity.

And, then we place the rods into the spine and we attach the screws to the spine, to the rods.

And then, and then we perform the correction, it happens in a pretty rapid sequence, actually.

It's sort of remarkable.

So while doing that, too.

I'm trying to think about muscles and ligaments that are already trained.

Just our bodies just naturally training themselves with muscle memory, etc.. So you're looking at now manipulating the way the spine is now that it's straight, and you may have some muscles that have been for their entire lifetime a certain way, how how does the recovery of this type of surgery occur with physical therapy?

Obviously, maybe the stretching of the muscles.

Yeah, it's a very it's a very rapid process.

So really hard, really fast.

And the it's it's essentially a kind of just a brute force effort and you get it and straight as you can.

Interestingly, over the next day or so, the patients shape of the back will continue to change as the metal tries to get back to its bent pre bent shape.

Right.

So when we put the rods in and actually we'll change the shape of the metal like much like a spring.

And then as the patient lies in bed the, the this elasticity of the tissues will allow the rods to continue to change shape over the next several days while the what the patient is.

So the patient's back will actually look different a couple of days after surgery, which is why taking an immediate film after surgery doesn't make a ton of sense.

Because backs look different a few days later, right?

You know, because the body is trying to work itself into that.

Yeah.

The the the tissues are responding to the metal as the metal tries to recover its shape.

You know, the the metals that we use are, very tough and a and they try to get back to the shape that they were in when they were placed.

And so at some point, the forces in the spine and the forces in the metal are equal to one another and everything stops.

They get to be friends.

Yeah.

And at that point, then the fusion person and a lot of people think that the metal is the fusion, but the fusion is actually bones healing the bones.

And so, the, the rods and screws are brace.

That's temporary.

We scuff up the bones with a little drill, little burr and, bones.

Not very smart.

And knows how to do one thing and that's make bone.

Right.

So if it gets if it gets infected, it makes bone.

If it gets cancer, makes bone if it, you know, if you scratch it up, it makes bone.

So we scuff it all up and then it starts to create bone to try to heal.

Okay.

That's what it knows how to do.

And it will heal level the level because those bones are held, you know, static.

And so the bone kind of just grow over each each by each vertebral body, ultimately turning that section into a single bone.

Wow.

So that's what the fusion.

That's what the fusion is.

And once the bone, once there's one chunk of bone, right, then they can no longer deform anymore.

And, the power of the pedicle screws is that they can actually overpower the growth potential of the bones.

And so once we replace all that, it's pretty well locked into place.

Years ago, we would use it from the back using a set of rods and wires.

But then the front of the spine would continue to grow while the back of the spine was held.

And so the spine would actually spin around itself.

Okay.

It's called crankshaft deformity.

And it was a horrible problem, when it happened.

So the instrumentation we have now is extremely powerful and will actually shut down that growth.

So, so wherever we put it is, is generally where it stays.

So it's hopefully a one and done type procedure.

It's interesting how you put that together.

And I'm just thinking to myself off subject, but sort of on when you said bone knows how to do one thing, it makes more bone.

I've always been curious about bone spurs.

I know it's kind of off topic that you can probably answer that in a minute or two, like a bone spur occurs when I know somehow there's some kind of trauma to the bone.

The bone wants to, I guess, fix itself.

Is that where the spurs come in?

And then it goes into nerves?

Because I have a little bit on me too.

So who?

Whoever wants to answer that.

That's just a curiosity., It It's usually a reactive process.

Okay.

So I think if a bone gets injured or recognizes that something's happened to it, it wants to try to heal itself.

And so then you can get a bone spur.

And and sometimes there they're helpful and sometimes they're, they get in the way.

Why did the way should I have it removed?

Depends where it is.

It's right at my neck.

Right.

I can't turn this way.

Yeah.

Then maybe I should.

I can see you guys.

I'm not a pediatric anymore, but, this is, a nice transition, Dr.

Woiczik I'd love to talk about, hip disorders.

So there are hip disorders, and then there are complexities that go with them.

Some are common, some are not.

So I'd like for you to maybe start with wondering, what are some of the most common hip disorders that might be a problem, but relatively benign going into hip disorders will really it is impeding movement and walking, etc.. So there's a couple of things that we see with some frequency.

One of the most common things I see and treat is hip dysplasia and hip dysplasia really has two different varieties, so to speak.

The first is something that you're born with.

And so that used to be called congenital hip dysplasia or more commonly it's now called developmental dysplasia of the hip.

And that's usually a child that's born with some abnormalities in their hip, some instability in their hip.

And there are some risk factors of that occurs in, and then there's a second type of hip dysplasia that happens in patients who have neuromuscular disease, conditions like cerebral palsy, spina bifida, other syndromes.

And the two entities don't behave the same.

If you're born with hip dysplasia, we typically see it more in girls similar to scoliosis.

We also see it associated with children who are, breech in utero, and patients who have a family history.

And those are some of the most, typical risk factors that we see it in.

And so I think in the community, and even in the practitioners we've met with in the last few weeks, and they really know when to screen a child for hip dysplasia.

And so if you have a firstborn child that's female, that was breech in utero, and maybe there's a family history, they typically will get an ultrasound to assess their hip development at roughly 4 to 6 weeks of age.

Okay.

And treatments will be determined based on what the ultrasound and the exam findings are.

And that's a condition that you can monitor throughout growth, just like scoliosis.

It can change as you grow.

Neuromuscular hip disorders.

Hip dysplasia usually is something that develops as a child is impacted by their neuromuscular condition, cerebral palsy for example, is a condition that has muscle spasticity most commonly, and the muscle forces, being spastic or tight, can affect the hip development, which can make the hips over time subluxate or dislocate and come out of the hip socket.

Oh my.

Okay.

And the identification of those is a little bit older.

Maybe age three, maybe age five.

And some of it depends on the complexity and the diagnosis of the patient actually has, when children are more, functional and more ambulatory, they have less issue with hip dysplasia in neuromuscular conditions, whereas children who are wheelchair bound and aren't standing and walking routinely, they'll have more significant deformity that needs to be treated.

So treated.

That's the question now because I can see through two almost very different types of treatment depending on how their their lifespan is going to carry them.

Wheelchair bound is one issue versus being mobile is another.

Take whichever case study you would like and and go into how in, let's say, someone who is not in a wheelchair, someone who is mobile, but is having a difficult time moving around, how would you go in?

And again, I always think to myself, growing bones is such a thing.

You can't just go in and and fix it and let it be because there's stuff still happening in there.

How do you how do you do that?

Like how do you work that through?

So the, the approach is different, based on what's going on with the patient.

The child who's born with hip dysplasia has a very different treatment algorithm than the patient who has a neuromuscular condition.

Probably more commonly we see children with, I'll say run of the mill hip dysplasia where they're born with some hip instability.

And those patients, if you meet them at 5 or 6 weeks of age and they have some hip instability or immaturity, we'll place them in a Pavlik harness and a pelvic harness.

Pavlik harness, have a so it's, it's, it's a brace that is soft and Velcro.

So, and the the pictures of, this device show the baby always smiling.

It takes a few days for the baby to accommodate to it, but it's a brace that goes around their chest.

There's two straps.

It's kind of like a book bag almost.

And then there's two straps that hold the legs up and out, which I described to patients as the frog position.

Okay.

So you don't want the legs to stay together.

You want the legs to be separate.

And what that does, it allows the ball to be in the hip socket and have their best chance to develop.

There are different positions that the hip can be in where it's less less optimally developing if the legs are together.

So the hips flexed and out is how we typically treat them in a harness.

And how often are they in this harness?

Or how many times, how many hours a day, I guess would be it's, full time.

It's full time.

It's at least 23 hours a day.

So usually I tell parents the more it's on, the faster it comes off.

Okay, take it off for a bath.

And not every baby gets a bath every day.

But, some of the amount of time in the harness depends on the severity of the dysplasia.

If it's mild sometimes you can take it off sooner if it's more severe where the baby presents with a dislocated hip and it's not in the socket, the treatment is a little bit longer and potentially, for, for more months than what you might typically see.

Okay.

So we're talking months at a time.

We're talking yeah.

Most kids you do have a harness for three months.

There's, there's some full time where which is that 23 hour time.

And then there's some weaning where, and for most children that harness is successful.

It has a success rate of over 90% for typical hip dysplasia.

If I meet a baby with a dislocated hip, the success rate goes down to 60 to 80% with that brace.

And when you say, baby, we're talking brand new out of the gate, baby.

5 to 6 weeks of age, 5 to 6 weeks age.

You said that early.

Yeah okay.

Okay.

So for the babies who don't, or the pelvic harness isn't effective.

We have some other braces we can try, but sometimes those kids need surgery.

You asked earlier about, you know, what their function would be.

And, the interesting thing about this diagnosis is children are going to reach milestones.

When they reach milestones, they're going to sit on time.

They're going to crawl.

For the most part.

They'll stand in cruise furniture.

They'll walk on time with a dislocated hip.

It doesn't hurt and is often missed, and it will sometimes hurt.

It is often missed.

Yeah, interesting.

So sometimes we'll have a child come in at the age of two and someone, in preschool or a family member will say, why is your son walking on their tiptoe?

Why does one leg look a different length?

And if both hips are dislocated, they often have a waddling gait.

And sometimes it's really subtle and it's hard to pick up.

And those kids will for sure need surgery.

They don't get a palvik harness.

So here's a you know, it might be a difficult question if, and I'm thinking if you have your, well, baby checks, you have your yearly checkups after a certain year.

Do doctors know just general pediatricians know to look for this would I'm trying to figure out how to ask this question.

How would a parent know to look for this if they do not notice?

Like you said, it could be very, benign.

You don't really see it happening.

I don't know that parents would know to look.

I think pediatricians are trained to look for it based on the risk factors we talked about.

But quite frankly, sometimes it gets missed.

If you live in many European countries, kids get screened universally for this.

In the United States, we screen based on risk factors.

So not every child gets an ultrasound.

But it gets missed.

If it gets missed and we pick it up under the age of four, they have a very good chance of having it fixed successfully.

And having a normal, healthy hip for the rest of their life.

The later you are, when we pick it up, the options change of what you can do, and the outcome becomes a little bit less certain.

So we definitely try to find these and fix them young.

The remodeling potential of the hip joint is best under the age of four.

It can still remodel and grow and change up until the age of eight and even older.

So here I'm trying to think about materials being used.

Are we looking at just, again, physiologically, is it just bones that you're using?

Is there any outside material brought in?

So I'm just thinking about growing, you know, when you're putting something in place and child's going to outgrow whatever is being put into place, how does that factor in?

So if you're asking about, surgical correction, I am sure you brought that up.

Yeah.

For a dislocated hip.

A lot of what we do is, is just change their anatomy.

So there's not necessarily putting anything in like you would do in an adult.

Okay.

And, adults, you might put in a fake hip, right?

As we get older, we get arthritis in.

You can do a hip replacement.

Our goal is to avoid that.

Okay?

Okay.

To let the hip grow as best as it can.

So, putting a hip in requires training and skill to understand.

The procedure to place the hip back in the normal hip joint.

And then there's some augmentation procedures to either the femur bone, the thigh bone, or the pelvis bone above it, which is the roof that covers of all, and sometimes there's some graft, but there's typically not a lot of, implantation or techniques to do it that.

Okay.

And then we place patients in this really fabulous spiky cast that most parents hate, which is a body cast.

And that's on for roughly three months.

A body cast.

Yeah.

Which is just whatever.

Two year old child.

Yes.

Yeah.

A lot of screaming out.

Imagine wiggling around and you're giggling.

Not no, not no in a knowing way, I should say.

Because I do want to continue.

You have you have something to say.

So I want you to add to that.

I talked about see, I want to talk about clubfoot.

Now, there's a spike in cancer.

Yeah.

Do you want to describe what they look like?

I mean, when you say they look like fiberglass pants, I mean, more or less.

Okay.

And, so the kids stuck in a frog position, as you just described, and kind of like harness, but made of fiberglass.

And so you could imagine something that wraps around your entire the child's body and there's peeing and pooping and other good times for parents.

It's it it is, quite an experience for sure.

You know, very effective at what it does, but it's.

So I'm thinking this and we're talking about how difficult it is.

But let's talk about the success of this going forward.

Would you have talked about two?

And for the most part, there's a high percentage where the hips will then develop normally for the lack of a better word.

Correct.

So there is a fine reasoning to this.

There's a there's you know, what is the short time pain for long term gain.

Correct.

So I'd like to transition really quick.

So this is fascinating.

I'd like to talk about foot disorders.

And what is commonly called clubfoot.

If you can describe what that is either one of you can take that.

I don't know who that is her baby.

Okay.

Oh, right.

There you go.

Okay.

So how would you describe to the audience, first of all, what's it called again?

We call it clubfoot.

And what is happening in the bones of the foot with that condition.

So, a clubfoot has a fancy medical term called congenital, meaning you're born with it, talipes which means foot.

Equinovarus, means the shape and the position of the foot.

We call it a clubfoot.

I try to describe to parents the first time I meet them that I think it's mostly that the foot looks like a golf club.

The foot is down and in and it looks just like a putter or a small driver of a golf club.

But it's it's fixed.

It's not something that if you look at the foot, you can just quickly stretch it out and it'll look like a normal foot.

But again, similar to hip dysplasia, there's really two types of clubfoot.

There's an idiopathic clubfoot, which is the run of the mill clubfoot, where there may be a family history.

Sometimes it's the first child in the family who has a clubfoot.

It's a little bit more frequently seen in boys.

We don't exactly know why it occurs a little bit like scoliosis.

We know that there's some genetic component to it, but we have not figured it out.

But the baby is often found to have a clubfoot in utero at their 20 week ultrasound.

So sometimes I now meet parents with a baby inside, that will discuss treatment.

But those are the.

Can you do treatment?

Not in utero.

but we just discuss what's going to happen after the baby is born.

Okay.

And then, there's a non idiopathic clubfoot.

The other medical term for that is a teratologic clubfoot.

And those are clubfoot associated with other things.

Spina bifida.

Other syndromes neuromuscular conditions similar to hip dysplasia.

The treatments are similar but again different.

Based on what what the driving causes are for a typical clubfoot, which I took care of a couple of patients with today.

We do stretching casts.

So we start that roughly at about 3 or 4 weeks of age.

I do have patients who come to me after where the baby's a week old.

I try not to do that because I want the baby to go home and bond with their parents and vice versa.

Yeah.

There's no benefit to casting right away after the baby's born.

But we do a series of casts.

They happen every week.

And the casting technique was designed by a man named Ignacio Ponseti, who I met in 2010.

He was still working at the age of 94.

Oh, way to go.

But he learned how to cast club feet and to manipulate the feet instead of doing surgery on feet.

And you can correct the cast each, the foot each week.

And, at the end of the casting process, you typically get a well corrected foot.

Most babies need to have their Achilles tendon stretched or lengthened, because the foot doesn't want to quite get down to the floor.

And the only way to do that is to lengthen the tendon.

But they recover from it beautifully, and it doesn't leave a long term.

And how is that done?

How do they lengthen the Achilles tendon?

We cut it okay.

Well, it's this is a medical show.

Yes.

So that's what you need to do.

Yeah.

So we cut it with local anesthesia.

They don't have a general anesthetic or go to sleep, but it's a tiny little incision to stretch the tendon and, not healing process on its own.

Yep.

It heals within three weeks.

Okay.

And then the foot is corrected.

But like any growing child, the foot likes to come back, especially something that they're born with.

So they get braces.

And this is the hard part.

I think, for the family, the bracing protocol is for four years.

So for the first three months they're in the braces pretty much 23 hours a day.

And then they wean the braces so that when they're at walking age, around one year, they wear the braces at night.

And we do that because we found that the foot turns back in and reform.

So the deformity, if you start bracing under the age of four after four, is the likelihood that it will come back as lower.

It's still possible.

But if you can get so there's the weaning really doesn't happen other than wearing it at night versus correct seven.

Okay.

And then, you know, if parents are diligent with the braces, which is like really the biggest success, the child usually has a healthy, pretty darn normal foot that they can run, play soccer football with.

And they do really well.

We used to operate on club feet and we don't anymore.

And this gentleman who was, functioning and still going to work at, what, 94 years old, how did he And the reason I'm asking this, I'm just trying to think of, the idea of was surgery an option earlier, but now the bracing is really proving to be the best thing going forward when they when there were surgeries and assuming every now and again, they're probably still are if it's not caught on time, if I don't know.

So the history of Doctor Ponseti, I may not be 100% accurate, but, Doctor Ponseti, was from Italy.

He came to the United States and he worked in Iowa, and he felt passionately that clubfoot didn't need surgery because we found that the more surgery we did on clubfoot as adults, you have stiff feet, they have arthritis, they don't work very well.

They hurt and they're what you stand and walk on all day long.

So he, he started casting and presented us as pediatric orthopedics with 50 years of data showing we can correct these feet without surgery.

When I was a resident between the years of 2002 and 2007, there was some casting happening in this country.

But a lot of surgery was still done.

When I started my practice in 2008, we stopped operating on children's clubs and we started casting them, and that is now the standard across the world.

So say you, you don't get someone depending on where you are culturally in life, socioeconomic situations whatsoever, and you find someone who is two years old, you still try it, still you still try to cast.

So that's still the standard, the gold standard way of treating it.

At this point, you may still have to do some surgery, okay.

But the surgery that was previously described is a really big surgery where you stretch a lot of things, try to move the bones into different positions.

And again, it's very, it develops a lot of scar tissue and it becomes a stiff, small foot.

If we have to do surgery for a clubfoot in an older child who is mis, we try to do very little to the foot to get it to what we describe as a plan, a grade foot position where the foot's on the ground and it functions like foot.

Okay, so less is more.

So little bones are are, I'm always a little bounce.

I like to size a little bit young, but amazing.

Yeah.

Are amazingly plastic and, and will, respond to, to forces that are applied to them, which was a whole point of the Ponseti casting.

We use the same principle and in infantile scoliosis.

So we do see kids that are born with, idiopathic scoliosis that, that, you know, we'll show up to clinic with 40, 50, 60 degree curves.

And they're, you know, one year, one year to two years old.

Interestingly enough, using the same principles, you can cast a spine, for a really young kid.

And so we can actually have a fairly high success rate of curing scoliosis in the young child because of the plasticity of the bones.

And so, I do occasionally this, this process called EDF casting about the same time, Ponseti, he was doing his casting, a lady named Mehta was doing her casting on the spine and demonstrated very similar results, very, very high success rates.

And so we talking about a full body cast here as well.

This okay.

This is truly a full body cast that that is extremely here to here.

It's a I'm not sure which one's worse.

They're both horrible his cast or mine.

Yeah.

But we yes.

But we provide a bending and a rotational and extension sort of set of forces through the spine.

And, the success rate for, for, idiopathic infantile scoliosis, caught between 1 and 2 years of age with curves less than 60 degrees is approaching 90%.

So here's that question again too.

Unless you know what to look for, is it something that you can kind of see what I'm trying to think you probably could with a certain infantile scoliosis is a lot easier to pick up on the kids.

Okay.

Like you can tell that there's okay with a 40 degree curve.

It looks like a little tiny banana.

Okay.

So, so there are a lot easier to pick up on, but you'd be surprised how many people show up to clinic with their with their 12 year old.

Yeah, a ten year old girl.

And I was like, I had no idea.

Of course.

Yeah, yeah.

And we hear stories like that all the time.

We are.

We are kind of at, like the seven minute mark.

It just happens so, so fast.

We think, oh my gosh, is a whole hour to talk about.

But I'd like to kind of stop and see if there's anything that either one of you want to talk about this evening while you have the chance to do so.

I know that we covered like the big thing was covering spine, scoliosis, hips and the foot.

Is there anything else that you want to cover this evening while we have this time, I always think about what's new on the horizon.

You know what is new on the horizon with spines.

And this is me being selfish as a 58 year old, it's like, you know, I know that my I can feel it and see it every year.

I can see in photographs with a necklace that I wear, you know, the necklace is starting to, to do this.

What do we see in the future of treating spines?

I mean, I'm okay now.

Have been for a long time, but there's there's the worry.

Well depends I mean, I think for the adult that has had scoliosis, I think the, the standard of care is probably going to be what we call segmental instrumented fusion, which is what I do now.

The surgeries a lot better.

The surgical techniques a lot better, outcomes a lot better.

So I think that's that's where we are currently, and I don't, I don't I mean, there's been some people who have tried, using tethering techniques where they, but screws in from the side and they put a cord and then try to push it across.

The problem is, is that the the deformity has already formed.

And so, that that tethering process, unless the spine changes its shape, ultimately that material will fail.

And so that's the problem with taking the muscle memory of the of your, you know, 58 years worth of being, well, the bone shape, the muscle memory, just all the tissue tension that has developed over time.

I, I don't know that there's a lot of strong science to support that.

That's going to work out long term.

There's people trying different versions of that, to see if it works.

I'm having a hard time wrapping my head around the science there myself.

And I think a lot of us sort of struggle with that.

But at least they're trying and thinking outside the box a little bit.

I think the, the long term goal, probably for clubfoot and for scoliosis and many of these disorders is understanding the genetics.

Right.

And trying to in fact, try to I checked off ask about that.

Yeah.

We had a geneticist here, a couple of weeks back, and it was interesting understanding the genetics, but then being able to manipulate what you can manipulate.

And, she was talking about, I can't remember exactly what the what the wording was, but being able to manipulate and or if you're looking at the parents of what traits may carry down, how is that how is genetics right now working in your practice?

I think that in many circumstances we're working in concert with genetics team to understand, genetics.

What and what a specific diagnosis is.

We've come, very far with the number of genetic diagnoses we see.

I think specific to some of the things that I'm treating.

I think we definitely still have a ways to go to understand what happens to children and why.

There are other hip conditions that we treat.

One is called Perthes.

We don't really know why that happens.

Explain what that is, if you don't mind.

It's a change in the blood supply to the proximal femur.

The hip joint.

Yeah.

And it usually happens, mid first decade, so around four to 7 or 8 years of age.

But we have tried for years to understand why that develops.

We still don't know.

There's a lot of theory.

Same thing with clubfeet.

We don't really know why somebody gets a clubfoot and I think, while genetics has shown us a lot of promise, there's still plenty of things we don't fully understand.

And I think that's one of the, I think the beauties of partly why we're here is we have some really vast experience.

I'm a very humble person, but I will say 18 years of working in an academic center, I've learned some things that, I think we're really excited to bring here to El Paso, that patients have been leaving El Paso to seek care elsewhere.

And, you know, I'm colleagues with with providers in Dallas at Texas Scottish rate with folks at Rady Children's.

So we're here and we want to encourage families to come see us if they have a worry or concern.

And that's what I love about this community.

And little by little, and children's has been very good about bringing in specialists.

And on that note, I know that we are kind of an isolated community.

So we have people coming in Las Cruces, Demming, you know, in the trauma field, obviously.

Is trauma level one.

But thank you so much for being here.

We have literally like three minutes to talk.

Is there anything else that you want to add?

If not, I'll just kind of do a plug of how people can watch the show again or.

Any questions.

Wait, what's what is what's the most common question you get?

Maybe that would be a good question to ask.

To wrap this up, you know, one of the most common questions I get is what would you do if this were your child?

Of course.

And, yeah, when I was younger in my career, I. I was uncertain what to say.

And as I've gotten older, and I've seen enough children have different forms of treatment.

I feel much more confident being able to say what I would want to have happen to my own child.

And I think, that's a really, great bonus to have here in the community.

The three of us and our nurse practitioners have great experience, and we've all been doing this for well over ten years.

And so now that's an easier conversation to say.

This is what I would do if I were in your shoes.

Well, El Paso's very lucky to have both you all.

And thank you for coming.

And then we're going to figure out what your favorite Mexican food restaurants are, coming up in the next year or so and then trying to make food on your own, which is kind of fun.

I want to say thank you so much to El Paso Children's Hospital again for being on the forefront of bringing in different pediatric specialists.

That's been that's been really great.

We've been talking to Dr.

Marcella Woiczik And again, I have to spell your name out loud again I just I just love it.

W O I C Z I K And then doctor, John Heflin.

So Doctor Heflin is, specializing again, board-certified and pediatric orthopedic surgeon.

And spine specialist, and also Doctor Woiczik board certified pediatric orthopedic surgeon and hip specialist.

But also we're talking a lot about feet as well.

If you, tuned in a little bit late or if you want to watch this program again or really any program that the El Paso Physician has put on, you can do that in several different places.

You can do that.

KCOSTV.org or PBS El Paso.

Org, and just look local programs and find the El Paso physician, also the El Paso County Medical Society website and that is EPCMS.com and then also youtube.com.

You can just type in literally the El Paso physician and usually on YouTube, the search engine will bring whatever the latest show is that we've done.

But if there's a program that you want to see, that we did a couple of weeks ago, a couple of months ago, just type that in there and you can see it there as well.

This has been at pediatric orthopedic surgery.

And this is the El Paso Physician I'm Kathrin Berg.

Good night.

El Paso County Medical Society is a nonprofit organization established 1898 that unites physicians to elevate the health of the El Paso community.

We have been bringing the El Paso Physician Television program to your home for the last 27 years on PBS El Paso.

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