By Roger F. Widmann, MD and Peter Fabricant, MD

Adolescent idiopathic scoliosis (AIS) is a common musculoskeletal disorder. Although it is thought to be genetic, its true cause isunknown and thought to be a combination ofmany factors. It is characterized by a curvatureof the spine measuring greater than 10˚, and hasno other symptoms or pain. At 25˚, bracing isrecommended in growing adolescents, and if thecurve progresses to greater than 50˚, becomescosmetically unacceptable, or rapidly progresses,surgery may be recommended to correct thedeformity and fuse the spine. Although 2% to3% of the adolescent population is diagnosedwith AIS, less than 10% of these patients requireany surgical intervention.

Because AIS is a painless condition, affectedadolescents frequently are athletic and participate

in physical activities alongside their unaffectedpeers. In the event that surgery is required, one common concern is the ability to return toathletic activity postoperatively.

After evaluating a group of 42 patients whounderwent curve correction and spinal fusion atHSS over an average of 5.5 years after surgery,

Pediatric Connection®

A PUBLICATION OF THE PEDIATRIC MUSCULOSKELETAL DEPARTMENT OF HOSPITAL FOR SPECIAL SURGERY

Adolescent Idiopathic Scoliosis and YoungAthletes: an HSS UpdatePediatric Orthopedists

John S. Blanco, MD

Shevaun M. Doyle, MD

Daniel W. Green, MD

Cathleen L. Raggio, MD

Leon Root, MD

David M. Scher, MD

Ernest L. Sink, MD

Roger F. Widmann, MD

PediatriciansH. Susan Cha, MD

Lisa S. Ipp, MD

Stephanie L. Perlman, MD

Pediatric RheumatologistsAlexa B. Adams, MD

Thomas J.A. Lehman, MD

Emma Jane MacDermott, MD

Pediatric AnesthesiologistsVictor M. Zayas, MD

Chris R. Edmonds, MD

Andrew C. Lee, MD

Kathryn (Kate) DelPizzo, MD

MEDICAL STAFF

VOLUME 3 – ISSUE 2

WINTER 2011

(Continued on page 2)

Hospital for Special Surgery is anaffiliate of NewYork-PresbyterianHealthcare System and WeillCornell Medical College.

For more information about HSSPediatrics, visit http://www.hss.edu

The Pediatric Orthopedic Service provides coverage to the Phyllis & David KomanskyCenter for Children’s Health atNewYork-Presbyterian Hospital.

For more information about the Komansky Center, visithttp://www.cornellpediatrics.org

One of the more under-recognized forms of juvenile arthritis is spondyloarthropathy.Patients with this condition very often presentwith recurrent sprains, frequent tendonitis, andlow back pain. These children often visit multiplephysicians before seeing the rheumatologist, wherethe pattern of disease involvement is recognizedand the diagnosis of spondyloarthropathy is made.

Spondyloarthropathy is, by definition, “arthritis ofthe back,” and describes a pattern of arthritis thatcommonly involves the spine, sacroiliac joints,and inflammation of the tendons at their insertionaround the joints (enthesitis). In adults, low backpain is often the most significant component;however, in children, the disease may present withperipheral joint involvement. Spondyloarthropathymay occur alone or as part of a larger diseaseprocess such as celiac disease, inflammatorybowel disease, psoriasis, or Reiter’s disease.

Spondyloarthropathy may occur in associationwith a genetic marker known as HLA B27. The absence of this marker does not exclude thepossibility of a sero-negative spondyloarthropathy.In fact, these patients often have completely normal blood work.

In adults with more aggressive symptoms, this association with HLA B27 is linked to adisease entity known as ankylosing spondylitis.

Spondyloarthropathy: “Arthritis of the Back”By Alexa B. Adams, MD and Emma Jane MacDermott, MD

(Continued on page 2)

Pediatric Nursing at HSSNursing at Hospital for Special Surgery (HSS) has achieved its third Magnet designation, which isthe highest honor given by the American NursesCredentialing Center for excellence in nursing care.HSS was the first hospital in New York City toreceive this prestigious award and is the first in NewYork State to receive three consecutive Magnet designations. On our pediatric unit, all of the nurseswho take care of children receive special training inthe care of the hospitalized child. This includes acomprehensive approach to understanding the child’sdevelopmental and physical needs, along withincluding the family in the plan of care. Inpatientand outpatient nursing staff work closely with the interdisciplinary team, comprised of pediatricorthopaedic surgeons, pediatricians, a pediatric nursepractitioner, physical therapists, social workers, acase manager, and the child life coordinator. Ourgoal is comprehensive planning across the continuumof care to facilitate optimal patient outcomes whilemaintaining a friendly environment.

We know that safety is a paramount concern of children’s families. Our pediatric nurses take steps to ensure children’s safety while at HSS. Thesemeasures include:

• Maintaining the physical safety of children bykeeping side rails up at all times

• Double checking all pediatric medications and dosages

2

Adolescent Idiopathic Scoliosis and Young Athletes: an HSS Update (Continued)most (60%) had returned to sports at an equal or higher level of physicalactivity. Postoperative athletic participation included a wide variety ofsports and ranged from recreational to university varsity-level. The onlyvariable studied that correlated with return to activity at the same orhigher level after surgery was the lowest level of spinal fusion, which isdetermined by the size and extent of the spinal curvature.

While patients are typically allowed to return to sports 6-12 months aftersurgery, this study indicated that the lowest level of fusion might predictthe patient’s actual likelihood of returning to play at or above the preop-erative level. Further ongoing research at HSS will elucidate why this isthe case, but the data collected here may help guide patient and familyexpectations regarding return to athletic activity.

Spondyloarthropathy:“Arthritis of the Back”(Continued)Usually this diagnosis is established in patients intheir 3rd or 4th decade and is based on clinicaland x-ray findings of joint involvement. Better disease recognition and faster initiation of therapy in young patients with this condition haltsprogression of severe joint involvement. Early initiation of therapy inyoung spondyloarthropathy patients also results in fewer radiographicchanges and ultimately may lead to fewer patients fulfilling criteria forankylosing spondylitis.

The medications used to treat spondyloarthropathy range from nonsteroidal anti-inflammatory drugs to traditional disease modifyingagents, such as methotrexate, to the now commonly used biologic agents.

Children with spondyloarthropathy are at increased risk of an inflammatoryeye disease called iritis, which usually presents with a painful red eye andmay be the presenting symptom of disease. Young patients with this condition should be seen regularly by a pediatric ophthalmologist.

Prompt recognition and treatment of juvenile spondyloarthropathy resultsin better long term disease outcomes. At Hospital for Special Surgery,the Pediatric Rheumatology Department is happy to provide any childdisplaying symptoms of childhood arthritis with the advice and treatmentthey need.

(Continued on the back page)

The Connection Inspection: A High School Athlete’s Comeback After Spinal Fusion

3

When the parents of MadisonDeRose learned that their 14-year-old daughter’s adolescentidiopathic scoliosis had progressed,despite the full-time Boston braceshe’d been wearing for more thana year, understandably, they were concerned.

Madison, an accomplished soccer,lacrosse, and basketball player

about to embark on her high school career, had been unaffectedby her scoliosis since first detected in the 2nd grade. Despiteconservative treatment by Shevaun Doyle, MD, AssistantAttending Orthopedic Surgeon at Hospital for Special Surgery,the curve progressed beyond 50 degrees in May 2010 andrequired surgery. With the start of school (and soccer season) just three months away, the need for expert surgicalcare was critical.

Dr. Doyle referred the DeRose family to Roger F. Widmann, MD,Chief of Pediatric Orthopedic Surgery at HSS, for surgicalmanagement. Madison’s mother explains how her concern forher daughter’s health and athletic career was alleviated uponmeeting with Dr. Widmann. “I really appreciated Dr. Widmann’sattitude,” she says. “Knowing that athletics was a big part ofMadison’s life, he reassured us that spinal fusion would notchange who she was as a person, and that she could resumeher life as an athlete three months after surgery. Even thoughMadison was having major surgery, we did not feel like it wasthe end of the world. It almost felt routine,” says Mrs. DeRose.

In August 2010, Dr. Widmann performed the six hour surgerywith great success. Madison was fused to L2 (2nd lumbar

vertebrae) with a dual rod construct and multiple pediclescrews. “Her scoliosis was typical,” says Dr. Widmann, “buther high level of physical activity and the demands she wouldplace on her fusion were not. Her expectation was that shewould be able to play contact sports again – and my goal wasto get her back to full activities, including athletics, 12 weeksfrom the date of surgery.”

Madison recovered from surgery at home, taking several walksa day to build up her strength, as prescribed by Dr. Widmann.One month following surgery, Madison walked through thedoors of Irvington High School for her first day of freshmanyear. “I had barely any pain,” she says. “Three months aftersurgery I went back to playing basketball and had no difficultyat all. Later that year, I made the varsity lacrosse team andwent on to be All-League. I got back to playing soccer the following fall,” explains Madison.

Dr. Widmann, along with Dr. Daniel W. Green, Associate Attending Orthopedic Surgeon at HSS, continues to evaluatethe impact of spinal fusion on patients like Madison after surgery. Through the HSS Return to Sports research study,Drs. Widmann and Green seek to determine the parametersmost closely associated with post-operative surgery and anearly return to sports, including length of the fusion, level of fusion, and pre-operative activity. This ongoing study, inwhich Madison is a participant, aims to enroll 90 patientsbefore completion.

Now a year after surgery, Madison continues to be a seriousathlete whose dream of playing college sports is well withinreach. “Thanks to Dr. Widmann and the rest of the Hospital for Special Surgery pediatric team,” Mrs. DeRose says, “she’sstill Madison, only straighter.”

HSS Welcomes New Pediatric OrthopedicSurgeon, Emily Dodwell, MD, MPH, FRCSCHospital for Special Surgery pediatrics is pleased to welcome Emily Dodwell, MD, MPH,FRCSC, a new Assistant Attending Pediatric Orthopedic Surgeon at HSS. Dr. Dodwell joins us from the Hospital for Sick Children in Toronto, Canada, where she served as a ClinicalFellow in Orthopedic Surgery. Specializing in general pediatric orthopedic surgery, pediatrictrauma, cerebral palsy, and limb deformity correction, Dr. Dodwell treats children of all ages. Dr. Dodwell treats patients with a wide variety of musculoskeletal issues, including fractures, ligament and tendon injuries, congenital deformities, cerebral palsy, growth disturbances, anddisorders such as osteogenesis imperfecta, Perthes disease, and skeletal dysplasias. Dr. Dodwellis dedicated to improving pediatric orthopedic care through orthopedic research that focuses onsurgical outcomes and disparities in health care for pediatric orthopedic patients.

Dr. Dodwell completed her medical doctorate at Queen’s University in Kingston, Ontario,Canada and her orthopedic residency training at the University of British Columbia, Vancouver,Canada. She has a Masters of Public Health from Harvard and attained her sub-specialty training as a pediatric orthopedic surgeon at the Hospital for Sick Children in Toronto, Canada.

The recipient of numerous awards, grants, and scholarships for her work, Dr. Dodwell most recently was awarded the OrthopedicEducation and Research Foundation/Ruth Jackson Orthopedic Society’s Career Development Grant and the North Pacific OrthopedicSociety’s Resident Research Award. She is a member of several professional medical associations including the American Academyof Orthopedic Surgeons and Pediatric Orthopedic Society of North America.

535 East 70th StreetNew York NY 10021

NON-PROFIT ORG.U.S. POSTAGE PAID

PARAMUS, NJPERMIT NO. 970

Pediatric Connection®

A PUBLICATION OF THE PEDIATRIC MUSCULOSKELETAL DEPARTMENT OF HOSPITAL FOR SPECIAL SURGERY

www.hss.edu/peds

Editor Shevaun M. Doyle, MDFor inquiries, please call (877) HSS-1KID or e-mail: Peds@hss.edu

Find us on Facebook at www.facebook.com/HSpecialSurgery.

Follow us on Twitter @HSpecialSurgery#hsspeds.

Watch us on YouTube.

Download our app.

©2011 Hospital for Special Surgery. All rights reserved.

Pediatric Connection® is a registered trademark of Hospital forSpecial Surgery.

Pediatric Nursing at HSS(Continued)• Using two identifiers, name and date of birth, prior to administration

of medications

• Use of an electronic monitoring system to notify nurses and securityif a child leaves the unit for any unscheduled reason

Pediatric nursing at HSS includes a pediatric nurse practitioner (PNP). The PNP is a continued presence and resource for the nurses as well as families. The PNP participates in the care of children andprovides patient and family education as needed. In addition, the PNPmeets daily with the interdisciplinary team and rounds daily with the pediatricians for ongoing care. The PNP works closely with thepediatric social workers to meet the child’s and family’s needs while atHSS, as well as for discharge planning to ensure continuity of care. The PNP is also involved in ongoing training of the staff to providepediatric-specific education.

Children at HSS receive the best of care, as our nurses work as a team to enhance the child’s and family’s experience. With the opening of the new Lerner Children’s Pavilion, we will be able to provide tailored collaborative care for all of our pediatric patients and their families. We look forward to continuing our tradition of excellence in pediatric care.