Innovative surgery preserves limb growth for childhood bone cancer patients

DALLAS – Dec. 11, 2024 – Arlette Chavez was a typical 3-year-old who loved jumping on the bed, riding her bike, and playing tag, said her mother, Lesly Rivera. When this active preschooler started complaining of pain in her left arm, Ms. Rivera and her husband, Carlos Chavez, weren’t overly concerned – it was probably a minor injury, they reasoned. But when an X-ray revealed a tumor on her left humerus, the bone that runs from the shoulder to the elbow, a biopsy soon confirmed that Arlette had a rare bone and soft tissue cancer called Ewing’s sarcoma. It is diagnosed in only about 200 children and teens each year in the U.S., according to the American Cancer Society.

Ms. Rivera’s immediate fear was that Arlette would need to have her arm amputated. Other options might include replacing the affected bone with cadaver bone or a prosthesis, which would limit Arlette in the future since her arm wouldn’t grow. But musculoskeletal oncologist Alexandra Callan, M.D., Associate Professor of Orthopaedic Surgery at UT Southwestern Medical Center and Pediatric Orthopedic Surgeon at Children’s Health, offered Arlette’s family a third option that would change their lives. Along with two of her colleagues in UTSW’s Department of Plastic Surgery, Dr. Callan performed an innovative 16-hour surgery at Children’s Medical Center Dallas that replaced Arlette’s humerus with bone from her leg, including the growth plate. The procedure not only saved Arlette’s arm but ensured its continued growth.

This technically rigorous and demanding operation is offered at only a handful of medical centers across the country. “It’s one of the most gratifying procedures that we perform,” Dr. Callan said. “Our No. 1 goal for these children is to get rid of all their cancer. But being able to rebuild their limb in a way that gives them the best function for the rest of their lives is truly rewarding.”

Innovating to prevent limb differences

Ewing’s sarcoma, osteosarcoma, and other bone cancers often impinge upon the growth plates of children’s arms and legs, explained Jonathan Cheng, M.D., Professor of Plastic Surgery at UTSW and Pediatric Hand Surgeon at Children’s Health, who specializes in complex limb restoration and peripheral nerve reconstruction. Consequently, the traditional limb-salvaging procedures used to treat these cancers often damage or remove the growth plate in these bones, leaving children with limb-length differences as they continue to grow.

“If the humerus isn’t the right length, then that impairs the ability of the hand to reach around and get where it needs to go,” said Dr. Cheng, who is also Chief of Pediatric Hand, Peripheral Nerve, and Microvascular Surgery at UTSW. “This can affect someone’s ability to get dressed, fix a sandwich, brush teeth, play an instrument or a sport, or even just shake someone’s hand.”

Five years ago, Drs. Callan and Cheng, along with their colleague Shai Rozen, M.D., Professor and Vice Chair of Plastic Surgery at UTSW and Plastic and Craniofacial Surgeon at Children’s Health, began performing the procedure that prevents these limb differences by transplanting a growth plate from the leg into the arm. Developed in Italy several years ago, this operation, called vascularized physeal (growth-plate) transfer, remains exceedingly rare in the U.S.

Dr. Cheng explained that after diagnosis, patients receive several sessions of chemotherapy to shrink their tumors, then receive extensive imaging so the three doctors can plan for these complex procedures. On the day of the operation, Dr. Rozen starts surgery at the patient’s leg, where he carefully dissects out the fibula, also known as the calf bone. It is one of two bones in the lower leg, along with the tibia (shin bone). The fibula bears only a tiny fraction of weight, and thus can safely be removed. Simultaneously, Drs. Callan and Cheng work together to remove the affected portion of the patient’s humerus, making sure to remove the entire tumor while reconstructing the rotator cuff in the shoulder and other critical structures.

Once these efforts are complete, the surgeons tailor a portion of the fibula that includes the growth plate to align with the remaining portion of the humerus and use it to replace the resected bone. Because extensive hardware can weaken the bone, they use only one or two screws to secure the transplanted piece. The entire procedure takes up to 16 hours.

“As reconstructive surgeons, we have collected skills over our entire careers that we might not need today, tomorrow, or next year, but are ready to use when we need them. There was no big learning curve when we began offering this option for patients, because we routinely use the skills and tools necessary for this procedure when we perform others,” Dr. Cheng said. “It’s a demanding day in the operating room, but we are well prepared for everything to flow smoothly.”

Assembling a dream team

One reason this procedure is so rare is because it requires all three surgeons to have complementary expertise and comfort working together on the same day, said Dr. Rozen – something difficult to find at even the largest academic medical centers. Drs. Rozen and Cheng, both experts in microvascular surgery and peripheral nerve reconstruction, have collaborated frequently over the years with Dr. Callan and other surgical oncologists for complex reconstructions after tumor resections. Because they enjoy working together and support each other’s skill sets, deciding to come together as a team for this unusual procedure was a no-brainer, Dr. Rozen said.

“Having a close-knit team that communicates and innovates and collaborates has been key to making this happen. It all comes out of the friendships that the three of us built together over the years,” he said.

So far, the surgeons have performed this procedure on six children with bone cancers affecting their arms. To track outcomes, they maintain a prospective database with information on patients’ functional abilities, limb growth, and other measures after the surgery. All patients so far have had continued growth and can use their affected arms.

Today at 8 years old, Arlette likes climbing monkey bars at the playground, putting her own hair in a ponytail, and taking jazz dance classes. She dreams of becoming a dance teacher. Her affected arm has grown 5 centimeters, or nearly 2 inches, since she had the surgery shortly after her fourth birthday.

“We were very lucky that this surgery is offered right in our hometown,” Ms. Rivera said. “I constantly compare that affected arm with her other arm, and it looks perfectly fine. It still doesn’t have the same strength as her other arm, but nothing has stopped her – she finds a way to do everything she wants to. My biggest hope is that her arm continues to build muscle and get stronger so that someday she’s able to use it at its full capacity to do anything she desires.”

Drs. Callan, Cheng, and Rozen are members of the Harold C. Simmons Comprehensive Cancer Center at UT Southwestern.

Dr. Callan is a Dedman Family Scholar in Clinical Care.

About UT Southwestern Medical Center   

UT Southwestern, one of the nation’s premier academic medical centers, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty members have received six Nobel Prizes and include 25 members of the National Academy of Sciences, 24 members of the National Academy of Medicine, and 14 Howard Hughes Medical Institute Investigators. The full-time faculty of more than 3,200 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in more than 80 specialties to more than 120,000 hospitalized patients, more than 360,000 emergency room cases, and oversee nearly 5 million outpatient visits a year.

About Children’s Health℠

Children’s Health℠ is the leading pediatric health care system in North Texas and has long been recognized as a leader in pediatric health. Children’s Health campuses include Children’s Medical Center Dallas, Children’s Medical Center Plano and multiple Children’s Health Specialty Centers. With its academic partner, UT Southwestern, Children’s Medical Center Dallas is consistently ranked the #1 children’s hospital in North Texas and among the nation’s best pediatric hospitals by U.S. News & World Report. Its commitment to excellence and providing outstanding care across all aspects of pediatrics has resulted in being ranked across all specialty programs for seven consecutive years, including Cancer, Cardiology & Heart Surgery, Behavioral Health, Diabetes & Endocrinology, Gastroenterology & GI Surgery, Neonatology, Nephrology, Neurology & Neurosurgery, Orthopedics, Pulmonology, and Urology.

In addition, Children’s Health nurses have received the Magnet® designation for the past 14 years, the highest honor for nursing excellence, and the health care system has been named a 2024 top place to work by The Dallas Morning News, USA Today and Forbes and one of the 150 Best Places to Work in Healthcare by Becker’s Hospital Review for 13 consecutive years. In addition, Children’s Health was named one of Fast Company’s Most Innovative Companies of 2024 for its pioneering model to train physicians to treat children’s mental health.

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