Orthopedic Surgery
Specialty Centers
Center for Clubfoot
Clubfoot is a condition present at birth in which infants may have a number of abnormalities of the foot and lower leg, each with varying degrees of severity. The back portion of the foot may be tilted inward and the heel pulled upward that can result in walking on the toes. The toes are often pointed inward, and the foot will frequently have a high arch. With clubfoot, the foot is generally less flexible than normal and the muscles of the foot and the calf may atrophy or weaken. Since the severity of the condition varies from patient to patient, our clubfoot specialists tailor treatment to each patient's particular presentation.
Initially, all children are treated non-operatively, beginning with manipulation to improve the alignment of the foot, followed by application of a cast to maintain the new alignment. Generally five to eight casts are required to correct the clubfoot. If non-operative measures do not correct the deformity effectively, surgery may be recommended. Surgery should be performed between the age of six and 12 months to maximize growth and remodeling of the bones and muscles of the foot and ankle, which occurs rapidly in the first year of life. The procedure involves releasing (or loosening) abnormally tightened ligaments or tendons, such as the Achilles tendon, in order to realign the foot properly. Following the operation, a cast is worn for four to six weeks.
Most children born with clubfoot will be walking at the appropriate age and have normal use of their feet and ankles by school age. The majority go on to participate in a full range of activities, including competitive sports.
Center for Scoliosis and Spine Deformity
Scoliosis is an abnormal curvature of the spine that causes the spinal column to bend to the left or right. Abnormal curvature of the spine can occur in children at any age. The most common type of scoliosis is idiopathic scoliosis, which means that it occurs without a known cause. Adolescent idiopathic scoliosis, by far the most common type of scoliosis, develops between the ages of 10 and young adulthood and is seen more frequently in girls.
A small number of children develop a curvature of the spine during fetal growth in the womb. Congenital scoliosis occurs when bony portions of the spine fail to form properly or when normally separated segments of the spine fuse together during fetal development. The condition can range in severity from a minor deformity that involves only one segment of the vertebral column to involving nearly every level of the spine.
Neuromuscular scoliosis is caused by the presence of a neurological or muscular disease, such as cerebral palsy or muscular dystrophy. Unlike other types of scoliosis, the abnormal curves of the spine in this type of scoliosis are unpredictable.
The Center for Scoliosis and Spine Deformity cares for one of the largest volume of pediatric patients needing spine surgery in New York. Our pediatric orthopaedic surgeons work collaboratively with other pediatric specialists, including neurologists, pulmonologists and cardiologists, to ensure the best possible outcome for scoliosis treatment.
At Morgan Stanley Children's Hospital, we use the most advanced surgical techniques and technology to reduce post-operative pain and accelerate a return to normal function. This includes video-assisted thoracoscopic surgery to correct scoliosis curves via two approaches. With an anterior entry, the vertebrae are visualized and fused from the front through a chest wall opening. With the posterior approach, vertebrae are visualized and fused from the back. Our surgical team has extensive experience and a record of great success with these procedures.
Surgery may involve fusion to eliminate the vertebral growth plates and connect them with bone "bridges" to prevent bending as the child grows; removing the intervertebral discs; and/or inserting a rod to straighten the curve. Our pediatric orthopaedic surgeons continue to advance the field through the application and evaluation of new techniques to correct scoliosis, including minimally invasive surgical approaches.
Center for Neuromuscular Disorders
Neuromuscular diseases are characterized by an impairment of the central nervous system, which includes the brain and spinal cord, or the peripheral nervous system, which includes muscles, the nerve-muscle (neuromuscular) junction, nerves in the limbs, and the motor-nerve cells in the spinal cord. These disorders can result in the loss of muscle control and lead to muscle atrophy or spasticity.
Children with neuromuscular diseases are often developmentally delayed, and they may experience increased or decreased muscle tone, loss of muscle bulk, weakness, twitching, cramping, numbness and tingling. Patients with problems with the nerve-muscle junction may experience droopy eyelids, double vision, and weakness that worsens with activity. Some neuromuscular disorders can also cause difficulty in swallowing and breathing.
If left untreated, muscles that have too much tone or tightness, or too little tone, can interfere with function, cause pain and result in problems in the skeleton such as clubfoot, scoliosis, hip subluxation or dislocation, or muscle contractures.
The Center for Neuromuscular Disorders takes a proactive yet conservative approach to the management of pediatric patients. Interventions may include physical therapy, orthotics, and/or minute injections of botulinum toxin to alleviate muscle spasms or to loosen a muscle for therapeutic purposes. For most patients, this therapy can provide significant relief of symptoms for a period of weeks to months. Repeated injections are required to sustain its benefits over long periods of time. Surgery may also play a role in treatment and is one of many options the Center offers in the care of children with neuromuscular disorders.
Neuromuscular conditions that have their onset in infancy or childhood include:Cerebral palsy - caused by damage to one or more specific areas of the brain, usually occurring during or shortly following birth, that results in an inability to fully control motor function, particularly muscle control and coordination. Symptoms may include muscle tightness or spasm, involuntary movement, gait and mobility disturbances, abnormal sensation and perception, impairment of sight, hearing or speech, and seizures.
Spinal muscular atrophy - a condition that causes the muscles to weaken and waste away due to degeneration of nerve cells in the spinal cord.
Muscular dystrophies - a group of inherited disorders resulting from defects in a number of genes required for normal muscle function leading to a decline in muscle strength and bulk.
Motor neuron diseases - a group of progressive diseases affecting the motor neurons in the brain and spinal cord that can lead to weakness and wasting of muscles in the arms and legs initially. Some of these diseases lead to weakness and wasting in the muscles of the face and throat, causing problems with speech and difficulty chewing and swallowing.
Dermatomyositis and polymyositis - a group of muscle diseases that involve inflammation of the muscles or associated tissues occurring when the inflammatory cells of the immune system attack the blood vessels that supply muscles and skin.
Diseases of the neuromuscular junction - caused when the neuromuscular junction, the space where the nerve signal is passed from nerve to muscle, does not work correctly.
Myasthenia gravis - a disease in which the immune system attacks the body's own tissues at the junction between the nerve and the muscles. The disease targets the part of a muscle cell that receives signals from a nerve cell, causing fatigue and weakness of voluntary muscles, partial paralysis of eye movement, double vision, and droopy eyelids.
Congenital myasthenic syndrome - one of the many types of inherited diseases that affect the function of processes at the junction of nerve and muscle cells.
Peripheral nerve diseases - affect nerves in the face, arms, legs, torso and some cranial nerves, interfering with communication between the brain and muscles, skin, internal organs and blood vessels and causing pain or numbness.
Charcot Marie Tooth disease - causes damage to the peripheral nerves due to defects in the genes for proteins found in fibers that carry electrical signals between the brain and spinal cord and the rest of the body. Common symptoms include muscle weakness and wasting, as well as loss of sensation in the feet, lower legs, hands and forearms.
Dejerine-Sottas disease - an inherited neurological disorder in which the peripheral nerves become enlarged or thickened leading to muscle weakness, progressively affecting mobility.
Friedreich's ataxia - a neurological disorder caused by genetic defects that results in diminished energy production in cells, including those of the nervous system and heart. Symptoms include ataxia (loss of balance and coordination), difficulty with speech and swallowing, muscle spasms, loss of sensation, skeletal and cardiac abnormalities, and possible diabetes or glucose intolerance.
Myopathies - a group of diseases that affect skeletal muscles, causing weakening and gradual wasting of the muscles, especially of those closest to the center of the body.
Myotonia congenital - a genetic, neuromuscular disorder characterized by the slow relaxation of the muscles that can lead to delayed muscle relaxation and muscle stiffness.
Paramyotonia congenital - a genetic, neuromuscular disorder that causes problems with tone and contraction of skeletal muscles, leading to muscle stiffness and weakness mostly in the face, neck and upper extremities.
Central core disease - causes problems with muscle tone and contraction of skeletal muscles, leading to persistent muscle weakness and delayed motor milestones. Skeletal deformities, including joint dislocation and scoliosis, often occur as well.
Nemaline myopathy - a neuromuscular disorder characterized by muscle weakness, usually most severe in the face, the neck flexors and the proximal limb muscles. Patients often suffer from respiratory problems, and infants commonly have problems with feeding.
Myotubular myopathy - a group of disorders that cause problems with the tone and contraction of skeletal muscles that can result in severe muscle weakness and lack of muscle tone with an inability to maintain proper posture and movement.
Periodic paralysis - rare disorders of the voluntary muscles characterized by episodes of attacks of muscle weakness.
Metabolic diseases of the muscle-caused by different genetic defects that impair the body's ability to process chemical reactions that occur within cells during normal functioning, resulting in muscle weakness, pain or cramps.
Phosphorylase deficiency (McArdle's disease) - a muscle disease that interferes with the processing of carbohydrates to draw energy from food, resulting in symptoms that include cramps, muscle pain, muscle weakness and exercise intolerance.
Acid caltose deficiency (Pompe's disease) - caused by complete or partial deficiency of the enzyme necessary for the breakdown and conversion of glycogen into glucose, which eventually leads to severe muscle degradation.
Phosphofrucokinase deficiency (Tarui's disease) - also interferes with the processing of carbohydrates to draw energy from food, leading to symptoms that include exercise intolerance, pain, cramping and occasionally myoglobinuria or rust-colored urine indicating breakdown of muscle tissue.
Debrancher enzyme deficiency (Cori's or Forbes disease) - affects the breakdown of glycogen, the stored form of glucose, resulting in generalized weakness and muscle wasting, enlarged liver in infancy, and episodes of low blood sugar.
Mitochondrial myopathy - a group of diseases affecting the mitochondria, small structures located outside of the nucleus in the cytoplasm that are responsible for energy production in cells. During physical activity muscles may become easily fatigued or weak and be accompanied by nausea, vomiting, headache, seizures, stroke-like episodes, droopy eyelids, blindness, deafness, heart failure and heart rhythm disturbances.
Carnitine deficiency - interferes with the processing of fats to draw energy from food and can result in cardiac disease, muscle weakness in the hips, shoulders, upper arms and legs, as well as in the neck and jaw.
Center for Pediatric and Adolescent Sports Medicine
In growing children, sports injuries involving bones, muscles, ligaments, tendons and joints are often quite different from conditions more commonly seen with older patients. The Center for Pediatric and Adolescent Sports Medicine offers comprehensive care to children and teens who have an injury or condition affecting sports performance, exercise or activity. The Center specializes in advanced arthroscopic surgical techniques for sports related injuries of the knee, shoulder, and elbow.
ACL Injuries
The anterior cruciate ligament (ACL) is one of the most important of four strong ligaments in the knee connecting the lower leg bone (tibia) to the thigh bone (femur). As the major stabilizing ligament in the knee, the ACL is also one of the most commonly injured. A tear in the major ligament that connects the thigh bone to the shin bone, ACL injury occurs more frequently in individuals who participate in high-risk sports such as basketball, football, skiing, and soccer. The ACL can give way in several ways: from rapidly changing direction, twisting the knee, or landing awkwardly from a jump.
Our Center provides particular expertise in managing ACL injuries in the pediatric and adolescent patient population whose injuries must be managed differently than adults because they are still growing. Standard ACL reconstruction techniques violate the growth plate, the area where the bone is still growing, putting a skeletally immature patient at risk for arrested growth. Historically, surgical treatment was delayed until the adolescent reached full growth potential - 14 years of age for girls and 16 for boys. Treatment prior to surgery consisted of avoiding sports, bracing the knee, and strengthening the muscles surrounding the knee.
However, without surgery, young patients, just like adults, are at risk for developing cartilage injuries and meniscal tears making surgery and recovery more difficult when the time comes. Our orthopaedic surgeons modified the ACL reconstruction techniques to minimize injuring the growth plate and allow surgeries to take place at a younger age.
This growth-plate-respecting ACL technique uses a soft tissue graft typically taken from the hamstring. Soft tissue across the growth plates does not arrest growth in the same way a piece of bone across the growth plate does. Our surgeons also use smaller diameter bone tunnels minimizing disturbance to the bones. This procedure can be performed on patients as young as six years old. The surgery provides the child or adolescent with knee stability into adulthood. If the knee becomes unstable in later years, then patients can undergo the standard adult ACL reconstruction with great success.
Shoulder Instability
Shoulder instability, which can lead to dislocation of one of the joints in the shoulder, is a common problem of young athletes who participate in throwing sports. Of all the joints in the body, the shoulder joint offers the greatest range of motion. This flexibility, however, can also predispose the shoulder to dislocation and instability. The shoulder's muscles, tendons, and ligaments work together to maintain stability. When these soft tissues are injured, they can no longer provide appropriate support and the joint begins to feel loose or may become dislocated. Shoulder instability often affects young and active individuals, and athletes, in particular. Our pediatric orthopaedic surgeons use arthroscopic techniques to correct post-traumatic shoulder instability, as well as to repair and strengthen the ligaments that keep the shoulder in the joint.
Elbow Injuries
Elbow injuries are common in throwing sports, often affecting the ulnar collateral ligament-the main ligament that holds together the bones of the lower arm (ulna and radius) and those of the upper arm (humerus) at the elbow and prevents them from moving abnormally. When this ligament ruptures, the elbow joint becomes unstable. Our surgeons have particular expertise in performing the "Tommy John" surgery in which the damaged ligament is replaced with a tendon from elsewhere in the body.
Tumor and Bone Disease Service
In collaboration with the Herbert Irving Comprehensive Cancer Center and the Herbert Irving Child and Adolescent Oncology Center at NewYork-Presbyterian/Columbia, the Tumor and Bone Disease Service offers an exceptionally comprehensive approach to the diagnosis and treatment of bone and soft tissue diseases in children and adults. These include:
- benign tumors and osteosarcoma
- metastatic disease
- metabolic bone disease, including osteogenesis imperfecta
- rare bone disorders, such as fibrodysplasia
- genetic bone disease
- cartilage disorders
- infections
An exceptional team of specialists in adult and pediatric medical oncology, reconstructive surgery, radiation oncology, radiology, and musculoskeletal pathology build on their extensive research and clinical expertise to offer patients a wide range of medical and surgical treatment options. These include advanced reconstructive techniques, limb-saving surgery, and clinical trials with novel therapeutic modalities for sarcoma.
Patients requiring complex surgical reconstruction for limb-length discrepancy, deformities, or posttraumatic complications, such as nonunion and painful joints, benefit from allograft cartilage transplantation, bone allografts, custom-designed expanding tumor prostheses for growing children, and microvascular reconstructive surgery.
