 Welcome to Much More on Medicine on the ThinkTech Live Streaming Network series, broadcasting from our downtown studio at Pioneer Plaza in downtown Honolulu. I'm your host, Catherine Norr. Joining me in the studio today is Dr. Kent Runker. Today, we're going to talk about innovation in kids' bone surgery. Remember that our talk shows are streamed live on the internet from 11 a.m. to 5 p.m. every weekday. And earlier shows are streamed all night long. All our shows are streamed on livestream.com. If you want the links to our live streams or previous broadcasts, which are available on youtube.com, or if you want to subscribe to our programs or get on our mailing list and get our program advisories, go to thinktechboy.com. I'm delighted to be talking with Dr. Kent Runker today. He's currently a clinical professor for University of Texas Health Sciences Center. He was a chief surgeon and chief of medical staff at Schreiner's Hospital for Children in Honolulu from 1989 to 2001. Before that, Dr. Runker was the chief of orthopedic surgery and director of orthopedic residency at Tripler Army Medical Center. He retired as a colonel in 1989. I know Dr. Runker because he's the author of a half dozen novels under the pen names Elaine Gunn and A.K. Gunn. Welcome Dr. Runker. It's great to have you. It's so nice to be here. Thank you very much. Okay, fantastic. So what does a pediatric surgeon do? A pediatric orthopedic surgeon, which is what I am, basically takes care of any kind of crippled children problem in children. And it's a very wide-ranging specialty. It involves fractures or scoliosis work or taking care of congenital abnormalities and genetic disorders of various sorts. Cerebral palsy, it's very wide-ranging, probably the most wide-ranging of all fields of surgery, really. Okay, and I have a plate and four screws in my wrist. And so what I was wondering is, would it be different for you to do orthopedic surgery such as an implant on an adult versus a child? Well, adults are pretty easy, actually, because you don't have to worry about growth. And as soon as you're talking about a child, you have to start talking about how the things are going to grow. So if you put in a plate, for example, and you have to make sure that the plate will grow as the child and the design of implants is important. So, for example, if I were to take a metal rod that I might use for spine surgery, that's normally five to six millimeters in diameter. If I take that and make it half-size for a small child, it will lose seven-eighths of its strength. So as we get smaller implants to be used on children's bones, which are smaller, then the strength goes down as well. So for children, we have to really redesign the implant completely for different age groups. Okay, so I'm curious. Does the work in orthopedic pediatric surgery, does that require creativity? It's probably the most creative of all surgical specialties, really, because we're constantly seeing kids that have things that we've never seen before. So every week in clinic, I would see some syndrome or disease that I hadn't seen before that has very unique problems associated with that. So it's one thing for me to see a child, for example, that has duplication of toes. So if you have six toes, that's fairly easy to handle. But if you've got seven toes or eight toes or nine toes, then that means I'm going to have to design an operation to take care of your particular problem. And it's not going to be like any operation I've done before. So I'm constantly faced every week, probably, I do a surgery that is very unique and designed specifically for that particular patient. So you mentioned that challenges with growth. Does that mean that as a child grows, that you have to do surgery to accommodate that growth in terms of putting different sizes of the implant in? Yeah, that's correct. So we have to, the three big problems are sizing it so that it'll do the job and have the strength to do the job plus stay around for long enough. So when you're talking about a child, the child has 70 years, 80 years of that the implant is probably going to be in the body unless it's taken out at some point. If I'm talking about an adult, it may be only need to be in for 10 years or 20 years. So a total hip that's put in a 70 year old is maybe going to be in there for 20 years. If I put a total hip and an 11 year old, then it's going to be in there for a considerably longer length of time. So we have to plan on that. Plus the children, we want them to grow. We don't want to put an implant in that will prevent the growth that they normally do. And the third thing is children are not going to be sedentary. They're going to do things that kids do. So I don't want to put something in that's not going to be allow him to go out and play and do all the things that a normal child can do. So, so we have specific problems in children that that are really we don't face so much in adults. And so is it do you enjoy working with children when it comes to doing implants? Oh, children are wonderful patients to begin with. And, and yes, if you design the implant properly and if it's if it's used properly, then you're and you you've thought out the problem that this particular child has, you're going to get great results, generally speaking. So it's a very happy profession. Actually, we we take kids we make we do something fairly not straightforward, but it doesn't take a huge surgery and we end up with happy results. 90% of the time you worked at Shriners for a period of time. Can you tell us a little bit about that Shriners was a wonderful place to work because we were taking care of kids from all over the Pacific and these kids didn't have access. Normally to to the orthopedic surgeons or even physicians frequently. And so we saw a lot of things that that would have been taken care of in infancy that were neglected and then became worse because they were neglected. So, so we could bring a child back from someplace like Fiji or Samoa do a a relatively straightforward operation for us and it would totally change the the child's life from then on. And that was very rewarding. It's it's it's an incredible charity and an incredible privilege to be able to do that kind of work. So do you find as a pediatric orthopedic surgeon that you do the same surgery over and over again like a lot of specialties because I know in Hawaii anyway we have orthopedic surgeons that are knee surgeons or shoulder surgeons or hip surgeons. But they don't really do surgery on more than one body part for adults. Is it different with kids? Yeah, it's it's totally different for kids. We if I'm in the operating and my first operating might be on an infant's hand, for example, and I might make an incision a centimeter long. And then the next case might be a two hundred and fifty pound kid that that is obese and has problems with growth of his knee because of that. And the next one might be something that is just totally unique that that I've never seen before or done before. So it's very diverse and and that adds to the fun. It's nice to be able to do something. And and generally speaking, you know, when I was in in full time practice, I very seldom had a week where I didn't do something that was pretty pretty unique to me. Do you find that you do joint replacements in children? We do do joint replacements. They they're the need is not as great as in as in the adult population. But at Shriners, we did maybe seven or eight joint replacements a year. And these were for very special problems, usually things like rheumatoid arthritis or infections of the hip that had destroyed the hip joint, things like that. Different different reasons, not just the osteoarthritis that is the mainstay for for adults. So what kind of issues do you find with joint replacements in children? Does that mean you have a joint replacement when you're 10 years old? Does that mean you have to have another joint replacement when you're 40 years old? Yeah, that's probably true. The the results of doing the joint replacements in children is is surprisingly good. They they do last 20 and 30 years frequently. And but I think to say that that the joint replacement is going to last for the entire time of the child's life is is probably being a little too optimistic. On the other hand, I don't worry about it a whole lot because when the child really needs a replacement, he's not going to get a replacement that's as good as what we have today. It's going to be a replacement that is 30 years in the future with all the technology that's going to be acquired in that time. And in the meantime, if I've given a child a tip that functions beautifully from age 11 to age 35 or 40, that that covers a very critical part of his life. And and to be able to do normal activities and and enjoy life like normal people during that period of time, you've really you've really done some good. So when you do surgery on a child, is their recovery time slower or faster than an adult? How does that work? Oh, it's amazing. You do. You do a large surgery on a child. They're bouncing back and and they're back to play amazingly quickly. Yeah, it's it's that's another happy thing. The surgery is tough. But but the kids bounce bounce back like little rubber balls off of a concrete floor. So with adults, you probably you have to try to get them to be active after surgery and they probably don't want to. So on the other hand, it sounds like with children, you don't even have to tell them, we're just going to do that. No, you have to you have to give them permission. You have to you have to say it's OK, you know, and and sometimes you have to have the physical therapist work with them to overcome their fear. But once they've done it once, they'll do it again. And if and, you know, if it doesn't hurt, then then they're they're they're often running. Well, it really does sound like kids are such a joy to work with in this environment. So OK, we're taking a short break. I'm Catherine Norr. This is much more on medicine on the think tech live streaming network series. We're talking with Dr Kent Ranker about innovation in kids bone surgery. Thanks to our think tech underwriters and grand tours, the Atherton Family Foundation, Carol Monli and the friends of think tech, the Center for microbial oceanography research and education, collateral analytics. The Cook Foundation, Dwayne Karisu, the Hawaii Community Foundation, the Hawaii Council of Associations of Abarbon owners, Hawaii Energy, the Hawaii Energy Policy Forum, Hawaiian Electric Company, integrated security technologies, Galen Ho of BAE Systems, Kamehameha Schools, MW Group, the Shidler Family Foundation, the Sydney Stern Memorial Trust, Volo Foundation, Yuriko J. Sugimura. Thanks so much to you all. We're back. We're live. I'm Catherine Norr and this is much more on medicine on the think tech live streaming network series talking with Dr Kent Ranker about innovations in kids bone surgery. So, Dr, what's an important innovation that you would like to tell us about? Well, the one that I'm currently writing about is the titanium rib. And this is a device that arose out of the basically trying to save children's lives. It's unusual for orthopedic surgeons to save people's lives. But this particular one does. And it was invented by a colleague of mine, a person that actually I became partners with at the University of Texas. And he has a Hawaii connection and that in that he did his internship at Trip Army Medical Center. And then he was faced with a child who had an absence of a part of his rib cage. And, you know, the rib cage works like a bicycle pump. If you have a bicycle pump, you depend upon this rigid tube to pump the air. If the tube isn't rigid, then it would suck in at the sides and you wouldn't get any air to flow. And the same way with our rib cage, the ribs coming around here stabilize it so that when you take a deep breath in, the soft tissues don't suck in on the side. And so this particular child had an absence of a part of his rib cage on the right side of his body. So he had a life expectancy of probably less than six months. And so something had to be done about this. And so Bob Campbell, the orthopedic surgeon, and Mel Smith, who was a thoracic surgeon, decided they would jury rig it and just use some wires that are used for fracture fixation to try to stabilize the rib. And it worked. And all of a sudden the child is off the respirator, is no longer in danger of suffocation. And the only problem is that those wires that they put in, basically wrapped around the rib at the bottom that was present and the one at the top, wasn't going to grow with the child. And he's otter age, so he's got a lot of growing to do. So what did they do in order to make that work for the growth? So Bob Campbell then worked out a system. He sort of thought, well, if I make something that works like a curtain rod, where you spread it apart and there's one part that slides inside the other part, then we can slide this apart, make a tiny little incision, put a little peg in to hold it out. And by doing that every six months this can grow with the patient. So that's where the creativity comes in. So this is, yeah, definitely creativity and design. So he shopped around and went to a custom device maker, implant maker in California, and they made one of these devices and put it in the child. And that was the first titanium rib. It was made out of titanium, which is everybody thinks titanium is really strong. That's not, that comes from its name. But the real value of titanium is that it doesn't rust at all. So it has very little wear problems. It can basically be in the body forever and last for decades within the body without rusting. This increased the morbidity of this trial? I mean, the increase, like, his length of life? Well, what happened with the child is that they put it in and there were two of the first implants. They basically ended up changing this out and about 20 years later he graduated from college. And he did have a demise in his 20s, but he got 20 years of good life from this device. Had he not had the device, what was the expected length of life? He would surely have not lived to be more than two years old. Okay, how old was he when it was implanted? It was put in when he was about 18 months old. Okay, so can we look at the image and maybe you can explain what it shows? Yeah, this is not that particular patient. This is another patient. But as you look on those gold things, those are the titanium ribs. One of them goes from rib to rib. The other one goes from the rib and then attaches down to the spine. And you can see that there are no ribs on that one side. So they're bridging this gap and stabilizing the chest. But the one that goes to the spine also, if you stretch it out, it's going to stretch out that curvature of the spine that you see. So this patient has not just a rib cage problem but a spinal problem as well. And by using this later design of what we call the Vepter device, it's vertical expandable prosthetic titanium rib. And that's a proprietary device. By using that, we can address both problems at the same time. Not just the rib cage problem but also the curvature of the spine. Oh, interesting. So what is the process of getting government approval of these devices? Well, the normal governmental approval problem is, first of all, you use it on animals first. And if you can't. In this case, you can't do that, really. And there's not a good animal model that it could be used on. So then you design whatever thing you think will solve your patient's problem. And you have to send that into the FDA. And after you've done a few of these, you're probably going to have to do a feasibility study. What's called a feasibility study. And what that is, is to basically indicate whether this is a safe procedure in a small number of patients. And that means sending data in on every procedure you do to the FDA. If that then works out, and then you'll do a larger study, usually in a multi-center study, in many different hospitals, and go through that process. And that then shows whether it actually solves the problem that you're trying to solve. The feasibility study is oriented towards safety to begin with. And then afterwards, you usually need larger numbers in order to prove that you're really solving the problem that you're trying to prove. Is most of the innovation done overseas or in the United States? The fact is, in spine surgery in particular, almost all of the innovations have come from overseas. Because it's been very difficult because of our really rather stringent laws and to get things developed within the United States. So a lot of the innovations in spine surgery have come from overseas, from Korea, from France, for example, for the spine implement plants that we do, and elsewhere. And the titanium rib was one of the exceptions to this rule. And that was due to a particular complex of events. Number one, because you're actually treating a life-threatening disease. And so if you have, you're given a little bit more leeway if you're saving kids' lives. So the FDA actually really worked together with the innovators in order to get this approved. Despite that, it took 17 years. Wow. 17 years of work before it got approved. Oh my goodness. So you mentioned you're writing about this. So what are you writing? Well, it's a very human story because you've got a lot of complications along the road. You've got very interesting people that were developing this. It's sort of a win-win story in a way because although the FDA had the obligation of proving that this was effective and a good thing to do, it wasn't, they helped. They really helped. It wasn't like they went overboard in order to ensure that this thing really got approved. Is that a nonfiction work or is that fiction that you're writing? This is nonfiction. Oh, okay. It's nonfiction, yeah. So if we want to read your fiction, how do we find it? Well, all of my books are on Amazon. Most of them are thrillers. I've got two mysteries out there. I publish all of the thrillers under a lane gun and then anything that's not a thriller goes under a K-gun. Very interesting, doctor. It's been terrific having you. So I'm excited because I've learned so much about pediatric orthopedics and I'm definitely going to take a look at your books. So okay, we're about out of time and we'll have to wrap it up. I'm Catherine Noor. This is much more on medicine on the ThinkTech live streaming network series. We've been talking with Dr. Kent Reinker about innovation in kids' bone surgery. Thank you for joining us today. Thanks to our broadcast engineer, our floor manager, and to Jay Fidel, our executive producer. It's all together. Please join us for future ThinkTech production.