4/7/2017 | by Resident Review Contributors
Interview with Dr. Freeman Miller
How long have you been practicing pediatric orthopedics and what made you interested in the field of NM disorders?
My interest in neuromuscular disorders started in medical school when I was considering whether I would do neurology or orthopedics. The problem I countered with neurology was that there was very little opportunity for actually making problems better. The diagnostic challenges were very interesting. Because I preferred to do direct intervention, I chose to enter orthopedics. My other interest was in engineering and mechanics. This interest also fit better with orthopedics. Therefore, when I completed my orthopedic residency and did a fellowship in pediatric orthopedics, the feasibility of doing gait analysis using computer assisted motion capture was just beginning. This opportunity matched perfectly with my interests in biomechanics and engineering as well as my interest in the complex diagnostic problems challenged by neurology. After I completed my pediatric orthopedics fellowship, I had a general orthopedic practice for four years until I moved to Dupont to start the Cerebral palsy program. For the past 30 years the majority of my practice has been children with Cerebral palsy.
What are the most common disorders that you treat? Do you also treat spinal pathologies in children with NM disorders?
My practice for the past 25 years has been almost exclusively focused on cerebral palsy and cerebral palsy like conditions. This means conditions limited to upper motor neuron disease which may include syndromes but does not include spina bifida, Myleomeningocele, or the muscle diseases. In my practice I treat all the orthopedic conditions associated with CP, this includes spinal deformity, upper extremity deformity, and spasticity management.
Over the course of your practice, what major changes have you observed in the field of NM orthopedics?
During my practice career, I have witnessed the development of ACP hip management protocols including screening, prophylactic management and well developed and highly established reconstruction protocols. This management has eliminated dislocated hips in children with CP in modern medical management systems. I have also witnessed the development of highly mechanized and efficient gait analysis systems that allows us to do complex multi-level reconstruction with confident expectation of good outcomes. During this time I have also experienced the fluctuating management of spasticity including the initial exuberant interest in dorsal rhizotomy in the late 1980s and early 1990s and the loss of enthusiasm in the late 1990's, to the rise in popularity of intrathecal baclofen pump's and botulinum toxin.
Over the past decade, different subspecialties have developed in the field of pediatric orthopedics. Do you believe NM disorders will soon become a separate subspecialty in pediatric orthopedics?
Neuromuscular disorders or a very large component of what makes up pediatric orthopedics. I believe all pediatric orthopedist will continue to manage a large spectrum of children with neuromuscular disorders. This includes children with mild hemiplegia and diplegia, monitoring hips in children with CP, treating mild sensory neuropathies, as well as monitoring children with Myleomeningocele. The current level of complexity in managing gate disorders in which there are often two or three levels of deformities especially in institutions for formal gait analysis is not available is not providing the child current best medical care. It is also inappropriate to expect a pediatric orthopedist who will see one complex multi level diplegic every two or three years to be able to provide maximum diagnostic and interventional treatment. It is exactly the same as expecting a pediatric orthopedist who will see one osteogenic sarcoma every two or three years to be able to manage that with the same effectiveness as a surgeon who is seeing 8 or 10 in a year. This is also true for hip reconstruction, I would expect most pediatric orthopedist to be able to do a simple hip varus derotation or open adductor lengthening, however to perform a complex neglected hip reconstruction in an adolescent would not be providing the best care if they only do this every five years.
In your opinion, do pediatric orthopedic surgeon require additional training to learn the optimal care of children with NM disorders?
This is entirely dependent upon their fellowship training. If a pediatric orthopedist trains in a hospital with a modern gait analysis laboratory and with the program with high-volume CP and other neuromuscular diseases, and the trainee spends considerable time like half of the fellowship focused in this area, then I feel they likely would be ready to enter practice and do most of the CP and neuromuscular cases if they are in a supportive environment where they have facilities like a gait analysis laboratory.
As an internationally well-known expert in the field, what is your recommendation for a trainee who is interested in the field of NM orthopedics?
I feel for a trainee considering pediatric orthopedics, they should also consider and develop an interest in the neuromuscular area especially in the treatment of CP which is by far the largest group and very much the most complex group in this population. The benefit of treating children with CP is that you have a long clinical follow-up. I typically see children from age 2 to 20 years every six months. This relationship allows me to understand the development of the child and the family. The complex decision making process has to include understanding the natural history of the deformity development, the proper timing for intervention in the deformity, and then having a clear expectation of the outcome of the interventions. Except for some rare complex deformities most of the surgical procedures encountered with neuromuscular diseases are relatively straightforward. Treating children with CP is the complete opposite of being a total joint surgeon. The total joint surgeon almost never has to consider what the correct treatment is, they only are focused on the technical execution of the treatment. This is the opposite in managing the child with CP, where 90% of the complexity is involved in diagnostic and temporal decision-making with only 10% involved in the technical intervention. To enjoy and appreciate treating children with CP it requires an individual who is comfortable and interested in this long term complex diagnostic challenge.
Gait analysis is a useful tool in evaluation of children with NM disorders but some trainees don't get exposure to gait analysis in their fellowship training, how can they learn more about this important diagnostic tool?
Gait analysis is a current mandatory aspect of managing complex gait problems in children with CP. For trainees who have not had the experience of understanding gait analysis or working with gait analysis who are interested in in managing complex gait problems in children with CP should develop a relationship to a modern clinical gait analysis laboratory, spend time to understand the data and the diagnostic information which is available. There are courses available which one can attend and if they have no experience with gait analysis laboratory in their training it also most likely means by default they have had no experience with modern CP management. Therefore if they are interested in modern complex CP management, they should consider doing a six or 12 months additional MN fellowship focused on neuromuscular disorders in a facility with a modern gait analysis laboratory with high volume CP management.
What do you find the most satisfying in your practice?
I most enjoy my long-term relationship with the families and patients. It is also very rewarding to develop increasing understanding of the natural history and the long term response to treatment.