Upper Extremity Injuries

 

by Jeff Cole, MD

Over the years, injuries and disorders of the hand and arm have not changed as much as their treatments. OrthoMemphis, a division of MSK Group, PC, has a team of sixteen fellowship trained physicians including three physicians who have focused their clinical training and practice to this aspect of the body. The physicians of the OrthoMemphis Hand Center have developed a brochure entitled "The Shrinking Wound, From Knife to Needle" that speaks to these changes. Recent advances in our subspecialty are allowing us to treat several common problems in a minimally invasive way when surgery is required, whether this is with a very small incision, or in some cases, just a needle puncture. This allows the patient to return to their maximum level of function as quickly as possible.

The OrthoMemphis Hand Center staff care for upper extremity disorders that begin with the newborn and affect patients through every stage of life. I join Bill Bourland, MD, and Dan Fletcher, MD, to offer more than 50 years of combined fellowship-trained experience in hand surgery. While orthopaedic surgery has become subspecialized, hand surgeons are often the sports medicine, total joint, pediatric, and trauma specialists for the hand and wrist. If an injury or problem involves the hand, our partners come looking for us.

Under our roof, the hand therapy and physician clinical areas were designed to be adjacent, allowing a cohesive team approach within the OrthoMemphis Hand Center. Hand surgeons and therapists can exchange information about a patient’s care, check wounds, and revise treatment plans as necessary. Sometimes we have what we call "combined appointments" when the physician and therapist see the patient at the same time. As some patients may have therapy a few times per week, there are other times when the therapist may walk down to discuss a patient’s progress. We may clarify an issue, advance a protocol or simply write a prescription. This communication is invaluable in keeping the patient on track with their recovery.

Focal to the minimally invasive message, one procedure done by the OrthoMemphis Hand Center physicians is the FAST^TM (Focused Aspiration of Soft Tissue) Procedure for chronic tennis elbow. This surgical technique was developed in collaboration with the Mayo Clinic. Diseased tissue can generally be removed in 15 minutes or less using local anesthetic. The technology is similar to that used for cataract removal from the eye, which has a 20 year track record. For the elbow, there is a device with a special probe (needle inside a needle) that vibrates back and forth 20,000 times a second. We are able to see the diseased part of the tendon with ultrasound and remove it with the probe which also irrigates a small bit of fluid and cleans it out. The older procedure used to require removal of the tendon attachment from the bone just to get to the unhealthy portion of tendon. This had to be repaired and the recovery was slow and far more painful. I am hoping I have done my last surgery for tennis elbow using the older method. Dr. Fletcher and I are leading the charge in the Mid-South area with regard to the FAST^TM

Procedure, and early results have been very encouraging. This has also been the case at the specialized centers across the country where this procedure is offered.

In addition, endoscopic carpal tunnel release has evolved over the last 20 years to become a procedure with only a fraction of the pain and recovery time compared to open technique. Among the three hand surgeons at OrthoMemphis, we have done upwards of 6,000 cases and have more than 40 combined years’ of experience with this procedure.

Dr. Bourland has become known regionally and nationally for his work with Dupuytren’s contracture. He was one of the first in the United States to use a needle-based technique for this relatively common hand ailment where some of the soft tissue in the palm of the hand begins to draw up or contract. This is a hereditary disorder and typically involves the ring and small finger, pulling them down into the palm. The classic open procedure for excision of the diseased tissue was fairly extensive. This was associated with a longer and potentially more complicated recovery. I said "was" because I am currently sending my patients to Dr. Bourland for the needle aponeurotomy procedure if they desire. The history is very interesting. He was first introduced to this procedure when a patient presented to his office with a stack of research articles and a video produced by a surgeon from France. He encouraged Dr. Bourland to learn the technique and schedule surgery whenever he felt ready to proceed. Fast forward seven years and Dr. Bourland now has patients flying to Memphis for treatment and blogging about their positive experience and result. This needle-based procedure is done using local anesthesia to numb the area. Some of the patients live in the Mid-South area, but many do not. He now devotes two days a week performing Dupuytren’s contracture procedures.

Our focus at the OrthoMemphis Hand Center is to deliver the best care possible for the patient. This is done through collaboration, new imaging techniques and blending of both new and classic surgical procedures, when needed, based upon evidence based medicine. Anyone with an elbow, wrist or hand problem should check with their primary doctor/healthcare provider, or contact us directly at OrthoMemphis.

Dr. Bill Bourland, Dr. Jeff Cole and Dr. Dan Fletcher

Memphis - Orthomemphis fellowship trained hand surgeon, Jeff Cole, MD has led the Tennessee Orthopaedic Society to record membership. As president of the Tennessee Orthopaedic Society, Dr. Cole has increased membership from 280 in 2010 to 400 in 2011. This explosion in membership has been driven by improving communication for best practices in patient care and practice management with Orthopaedic Surgeons across the state.

With the upcoming changes in healthcare, it is more important than ever to work as a cohesive state society to ensure that access to orthopaedic care and the quality of patient care are not affected by policy changes. Lobbyist Nathan Green represents the society in Nashville where he reviews all legislative bills and meets with congressmen to ensure the best interests of orthopaedic patients are represented. As the baby boomer generation age, it is critical that they have access to orthopaedic care for arthritic conditions for a better quality of life which leads to a healthier lifestyle.

Dr. Cole has been a part of the medical community in Nashville during Medical School at Vanderbilt, Chattanooga during residency and Memphis for his practice. With these experiences, he has been able to connect orthopaedic surgeons across the state and develop a society that fits their needs. For instance, in order to drive attendance for the upcoming annual society meeting, Dr. Cole moved the meeting to a centralized affordable location to allow surgeons easy access and cost effective travel. This move has brought record registration to the meeting. He also secured nationally renowned surgeon Ken Yamaguchi, MD to present on patient outcomes and partnered with TAOE for the practice management seminars.           

The mission of the Tennessee Orthopaedic Society is to advance the science and practice of orthopaedic surgery through education and advocacy on behalf of patients and practitioners, with emphasis on overall quality orthopaedic health care for the state of Tennessee.

OrthoMemphis Surgeons Selected for a Study of a Cartilage Repair Procedure for Knees

Drs. Randall Holcomb and Kenneth Weiss will be the first surgeons to enroll patients in Memphis in an investigational study of a single-stage cartilage repair procedure for the knee. The study will be a randomized, prospective multi-center clinical trial evaluating the safety and effectiveness of the Cartilage Autograft Implantation System (CAIS^TM), as a surgical procedure of cartilage lesion(s) in the knee compared to a standard surgical treatment called microfracture.

"Most clinicians involved in cartilage regeneration research agree that the future lies in techniques that utilize cartilage cells on a bio-scaffold. This investigational study utilizes this type of advanced technology and we are hopeful that this technology will prove to be a valuable tool for our patients who have knee pain related to cartilage problems," said Randy Holcomb, MD, a clinical investigator and sports medicine orthopedic surgeon at OrthoMemphis.

"This is a well designed clinical trial that will generate important evidence-based data on a potential alternative to the current standard procedure in the exciting new field of cartilage  repair," said Brian Cole, MD, clinical investigator and director of the Rush Cartilage Restoration Center in Chicago, one of the testing sites.

  "This investigational study will evaluate whether the CAIS technology has the potential to provide greater benefit than microfracture for the repair of cartilage defects of the knee."said Kenneth Weiss, MD, a clinical investigator and sports medicine orthopaedic surgeon at OrthoMemphis. Patients between 18 and 55 years of age, who have normal symptoms of focal knee pain, such as swelling, fluid in the knee, catching, limited motion or stiffness, may be considered for the screening phase of the study. The CAIS procedure is limited to patients with a small articular cartilage defect of the knee on the femoral surfaces (end of the thigh bone); and meet all other inclusion and exclusion criteria of the study.

 During the CAIS procedure, surgeons remove a sample of healthy cartilage from a non-weight or low-weight bearing area of the patient's knee. The tissue is broken up and combined with a unique absorbable material that provides a scaffold for cell growth. This scaffold is then implanted at the site of cartilage damage. The CAIS procedure can be applied in one surgical procedure.

 This multi-center clinical trial will compare CAIS to microfracture surgery to determine which procedure will better reduce pain and improve function levels of patients with damaged knee cartilage.  The trial will enroll up to 364 patients at up to 40 investigative sites throughout North America, and follow their progress for four years.

 Industry estimates indicate there are more than 400,000 surgical cartilage repair procedures performed each year.  The number of procedures is expected to rise with an increasingly active aging population. 

For more information on this trial, please call (901) 259-1600 extension 1508

My vote?  FAD!

by Casey Malone MPT, Cert. MDT, CMP

The full service clinic will be open to players who have urgent, non-critical injuries on a walk-in basis with no appointment needed. Again, an appointment is not necessary but you may call 901-261-2582 on your way to the clinic so the physician can plan for your arrival.  Most major insurance plans are accepted.  Injured players should have a referral if required by their insurance company and should be accompanied by a parent or legal guardian if under the age of 18.

What: OrthoMemphis Friday Night Football Injury Clinic

When: Temporary Clinic Hours on Friday Evenings from 8:00-11:00pm during High School Football Season: August 27- October 29, 2010

Where: 6286 Briarcrest Avenue

             Memphis, TN 38120

             901-261-2582 

OrthoMemphis also has a physician on-call to provide treatment for critical injuries at Baptist Memorial Hospital-Memphis and Methodist Hospital Germantown.

About OrthoMemphis

OrthoMemphis, a division of MSK Group, P.C., provides comprehensive orthopaedic care at 6286 Briarcrest Avenue in Memphis, including OrthoMemphis Spine Center & Physical Therapy.  The mission of OrthoMemphis physicians and staff is the provision of state-of-the-art, personalized orthopaedic care. OrthoMemphis currently has fourteen physicians.  The managing partner of OrthoMemphis is Randall L. Holcomb, M.D.  OrthoMemphis integrated with Tabor Orthopedics on May 1, 2008, forming MSK Group, P.C.  Memphis Orthopedic Group joined MSK Group, P.C. on August 3, 2009. To learn more about OrthoMemphis, visit www.orthomemphis.com.

###

The trend toward barefoot running is for relief from chronic injuries such as plantar fascitis, stress fractures and shin splints, which are thought to be linked to the trauma of striking the ground with the heel.  There are studies that show benefits of and demonstrate the different gaits between barefoot and shod running, though none are designed for a thorough comparison of the two.

Overall, I feel that barefoot running is more of a fad and will have a limited following in modern societies.

Now that he can walk, Craig Cain just wants to dance.

He danced on New Year's Eve, testing his reconstructed toes and two knee replacements by climbing stairs in Beale Street establishments that would've been impassable only months before.

Photo by Karen Pulfer Focht
Buy this photo »

Cain has spent most of his life bound to a wheelchair, but he recently began walking after having both of his knees replaced.

Photo by Karen Pulfer Focht
Buy this photo »

Regina Edwards moved her son, Craig Cain, to Memphis in 1995 because he needed special medical attention for his rheumatoid arthritis.

He danced at other clubs across Memphis, gradually building the confidence to try some tentative steps and meet people.

He dances so much nowadays that his mother, Regina Edwards, softly chuckles at how her son -- after a childhood of disability, social isolation and almost constant, excruciating pain -- sometimes doesn't get home until 2 or 3 in the morning.

After all, at age 22, Cain is making up for lost time.

"I feel like a new person," he says, "like I've got my life back."

It wasn't long ago that Cain's body was like a creaky old machine, breaking down one part at a time. First his toes balled up and froze in a bent position, then his knees failed and finally a hip and later a shoulder went out.

By the time he was a teenager, Cain was wheelchair-bound and unable to raise his arms.

The source of his trouble was an unusually aggressive and severe form of juvenile rheumatoid arthritis -- the worst case any of his doctors had ever seen. It had been coursing through his body since early childhood, attacking and destroying one joint after another.

"They (doctors) kept asking me, 'Is there anyone else in my family with it?'" said his mother. "No, he just popped up with it."

But now, the Hickory Hill resident is not only walking and dancing, but pursuing dreams of becoming a chef. He's living more of a normal life, thanks to a series of unusually complex surgeries.

During the past three and a half years, Cain has had his toes reconstructed and undergone operations to replace both knees, his right hip and, just last month, his right shoulder.

"We're hoping this is our last surgery," said Edwards.

The disease plaguing Cain is usually associated with middle or old age. But arthritis also is a pervasive childhood affliction that currently affects some 294,000 American kids under age 18, according to the Arthritis Foundation.

Rheumatoid arthritis, characterized by the inflammation of the lining of the joints, is one of the more common forms of juvenile arthritis. With no known cause or cure, it's an auto-immune disease that sometimes causes only mild problems, but often wreaks painful, life-changing damage by destroying joints and organs.

"Craig is truly a severe case," said Dr. Tim Krahn, an orthopedic surgeon with OrthoMemphis who operated on him.

"You don't normally see 21-22-year-old kids coming in with all their joints worn out."

Cain's journey, Krahn says, "is an amazing story."

It's one that can be traced to a small town outside Richmond, Va., where Cain and his family lived when he was a small child.

"Up until age 5, we had no problems," his mother said.

Cain has two older brothers who don't suffer from arthritis and are in good health. The first sign of his trouble was a rash on his knees, wrist and back. Then came the pain: lacerating jabs that could leave him screaming and crying at night.

A chronic fever made the ailment all the more mysterious.

For Edwards, the symptoms evoked fears that her son had multiple sclerosis, a disease that had killed her mother. But even after rheumatoid arthritis was identified as the ailment, doctors were flummoxed as to how to treat it.

"It seemed like anything that was supposed to work, it wasn't working for him," she said.

Casting around for solutions, doctors at a Richmond hospital planned to inject Cain with gold salts -- a well-established treatment that can reduce inflammation. But Edwards, a licensed practical nurse, researched the injections and vetoed them on the grounds that he was too young.

Dissatisfied with the treatment her son was receiving, she looked for a longer-term solution.

"I asked the doctor, 'Is there somewhere else where we could go for better medical treatment?'"

There was, came the answer. And the place? Memphis.

It was the reputation of the rheumatology specialists associated with Le Bonheur Children's Medical Center that prompted the Virginia doctors to refer Edwards to Memphis. She moved here with her sons in 1995.

Instead of the injections, doctors in Memphis tried gold pills. They worked for a while, Edwards said, but the disease continued to progress to the point that Social Security approved Craig's disabled status.

After years of walking with splints and braces, and undergoing painful physical therapy, he was limited to a wheelchair. The affliction had stolen any chance for a normal childhood.

"I couldn't go play sports, go out and have fun," he recalls. "I would basically sit in the house."

As the pain in Cain's knees and other joints grew worse, side effects of the disease took hold. Fluid build-up around his heart and lungs prompted a stay at St. Francis Hospital.

"He's had so many complications from that arthritis," Edwards said.

Cain's life soon revolved around a regimen of injections, pills and skin patches that delivered doses of everything from pain-killers to steriods. The treatments often made him nauseous, sleepy or depressed.

His graduation from Ridgeway High School in 2005 was a major achievement, but it also created a huge void in his life. Cain's friends were moving on, but, unable to get out and function, he was left behind.

"It was very depressing," he recalls. "I felt like I was in prison."

In an effort to cheer him up, Cain's mother bought him a dog, a Boston terrier, and arranged for him to get counseling.

But after nearly 15 years of dealing with the ravages of the disease, Cain was ready for a long-term solution. In subsequent visits to doctors, X-rays showed a total absence of cartilage in his knees -- just bone grinding on bone.

The operations to replace the knees would be anything but ordinary, however. The disease had been so severe that Cain's bone structure didn't develop normally, Krahn said.

"In Craig's case, the anatomy was very distorted."

But a new pre-operative navigation system developed by nearby Wright Medical Group provides doctors customized "cutting guides" based on CT or MRI scans. It helps ensure the implants are aligned correctly.

With his surgeries over -- assuming other joints won't need replacing -- Cain is now getting ready to learn how to drive. Then he wants to attend culinary school to learn to be a chef.

His mother, meantime, is enjoying freedom, too, now that she doesn't have to constantly care for Cain and take him to doctors. When reached by phone earlier this month, she was in Florida.

"I finally can go away and know that he's OK," Edwards says.

Cain still needs physical therapy, but he speaks like someone who has undergone a rebirth.

"That's what it feels like -- a second chance," he says.

Photo by Brandon Dill // Buy this photo

Rheumatoid arthritis sufferer Craig Cain has his shoulder stretched by physical therapist Sara Siler after his most recent of several surgeries in the last three and a half years. In addition to the shoulder surgery, he's had his toes reconstructed and had operations to replace both knees.

Now that he can walk, Craig Cain just wants to dance.

He danced on New Year's Eve, testing his reconstructed toes and two knee replacements by climbing stairs in Beale Street establishments that would've been impassable only months before.

Photo by Karen Pulfer Focht
Buy this photo »

Cain has spent most of his life bound to a wheelchair, but he recently began walking after having both of his knees replaced.

Photo by Karen Pulfer Focht
Buy this photo »

Regina Edwards moved her son, Craig Cain, to Memphis in 1995 because he needed special medical attention for his rheumatoid arthritis.

He danced at other clubs across Memphis, gradually building the confidence to try some tentative steps and meet people.

He dances so much nowadays that his mother, Regina Edwards, softly chuckles at how her son -- after a childhood of disability, social isolation and almost constant, excruciating pain -- sometimes doesn't get home until 2 or 3 in the morning.

After all, at age 22, Cain is making up for lost time.

"I feel like a new person," he says, "like I've got my life back."

It wasn't long ago that Cain's body was like a creaky old machine, breaking down one part at a time. First his toes balled up and froze in a bent position, then his knees failed and finally a hip and later a shoulder went out.

By the time he was a teenager, Cain was wheelchair-bound and unable to raise his arms.

The source of his trouble was an unusually aggressive and severe form of juvenile rheumatoid arthritis -- the worst case any of his doctors had ever seen. It had been coursing through his body since early childhood, attacking and destroying one joint after another.

"They (doctors) kept asking me, 'Is there anyone else in my family with it?'" said his mother. "No, he just popped up with it."

But now, the Hickory Hill resident is not only walking and dancing, but pursuing dreams of becoming a chef. He's living more of a normal life, thanks to a series of unusually complex surgeries.

During the past three and a half years, Cain has had his toes reconstructed and undergone operations to replace both knees, his right hip and, just last month, his right shoulder.

"We're hoping this is our last surgery," said Edwards.

The disease plaguing Cain is usually associated with middle or old age. But arthritis also is a pervasive childhood affliction that currently affects some 294,000 American kids under age 18, according to the Arthritis Foundation.

Rheumatoid arthritis, characterized by the inflammation of the lining of the joints, is one of the more common forms of juvenile arthritis. With no known cause or cure, it's an auto-immune disease that sometimes causes only mild problems, but often wreaks painful, life-changing damage by destroying joints and organs.

"Craig is truly a severe case," said Dr. Tim Krahn, an orthopedic surgeon with OrthoMemphis who operated on him.

"You don't normally see 21-22-year-old kids coming in with all their joints worn out."

Cain's journey, Krahn says, "is an amazing story."

It's one that can be traced to a small town outside Richmond, Va., where Cain and his family lived when he was a small child.

"Up until age 5, we had no problems," his mother said.

Cain has two older brothers who don't suffer from arthritis and are in good health. The first sign of his trouble was a rash on his knees, wrist and back. Then came the pain: lacerating jabs that could leave him screaming and crying at night.

A chronic fever made the ailment all the more mysterious.

For Edwards, the symptoms evoked fears that her son had multiple sclerosis, a disease that had killed her mother. But even after rheumatoid arthritis was identified as the ailment, doctors were flummoxed as to how to treat it.

"It seemed like anything that was supposed to work, it wasn't working for him," she said.

Casting around for solutions, doctors at a Richmond hospital planned to inject Cain with gold salts -- a well-established treatment that can reduce inflammation. But Edwards, a licensed practical nurse, researched the injections and vetoed them on the grounds that he was too young.

Dissatisfied with the treatment her son was receiving, she looked for a longer-term solution.

"I asked the doctor, 'Is there somewhere else where we could go for better medical treatment?'"

There was, came the answer. And the place? Memphis.

It was the reputation of the rheumatology specialists associated with Le Bonheur Children's Medical Center that prompted the Virginia doctors to refer Edwards to Memphis. She moved here with her sons in 1995.

Instead of the injections, doctors in Memphis tried gold pills. They worked for a while, Edwards said, but the disease continued to progress to the point that Social Security approved Craig's disabled status.

After years of walking with splints and braces, and undergoing painful physical therapy, he was limited to a wheelchair. The affliction had stolen any chance for a normal childhood.

"I couldn't go play sports, go out and have fun," he recalls. "I would basically sit in the house."

As the pain in Cain's knees and other joints grew worse, side effects of the disease took hold. Fluid build-up around his heart and lungs prompted a stay at St. Francis Hospital.

"He's had so many complications from that arthritis," Edwards said.

Cain's life soon revolved around a regimen of injections, pills and skin patches that delivered doses of everything from pain-killers to steriods. The treatments often made him nauseous, sleepy or depressed.

His graduation from Ridgeway High School in 2005 was a major achievement, but it also created a huge void in his life. Cain's friends were moving on, but, unable to get out and function, he was left behind.

"It was very depressing," he recalls. "I felt like I was in prison."

In an effort to cheer him up, Cain's mother bought him a dog, a Boston terrier, and arranged for him to get counseling.

But after nearly 15 years of dealing with the ravages of the disease, Cain was ready for a long-term solution. In subsequent visits to doctors, X-rays showed a total absence of cartilage in his knees -- just bone grinding on bone.

The operations to replace the knees would be anything but ordinary, however. The disease had been so severe that Cain's bone structure didn't develop normally, Krahn said.

"In Craig's case, the anatomy was very distorted."

But a new pre-operative navigation system developed by nearby Wright Medical Group provides doctors customized "cutting guides" based on CT or MRI scans. It helps ensure the implants are aligned correctly.

With his surgeries over -- assuming other joints won't need replacing -- Cain is now getting ready to learn how to drive. Then he wants to attend culinary school to learn to be a chef.

His mother, meantime, is enjoying freedom, too, now that she doesn't have to constantly care for Cain and take him to doctors. When reached by phone earlier this month, she was in Florida.

"I finally can go away and know that he's OK," Edwards says.

Cain still needs physical therapy, but he speaks like someone who has undergone a rebirth.

"That's what it feels like -- a second chance," he says.

Photo by Brandon Dill // Buy this photo

Rheumatoid arthritis sufferer Craig Cain has his shoulder stretched by physical therapist Sara Siler after his most recent of several surgeries in the last three and a half years. In addition to the shoulder surgery, he's had his toes reconstructed and had operations to replace both knees.

Now that he can walk, Craig Cain just wants to dance.

He danced on New Year's Eve, testing his reconstructed toes and two knee replacements by climbing stairs in Beale Street establishments that would've been impassable only months before.

Photo by Karen Pulfer Focht
Buy this photo »

Cain has spent most of his life bound to a wheelchair, but he recently began walking after having both of his knees replaced.

Photo by Karen Pulfer Focht
Buy this photo »

Regina Edwards moved her son, Craig Cain, to Memphis in 1995 because he needed special medical attention for his rheumatoid arthritis.

He danced at other clubs across Memphis, gradually building the confidence to try some tentative steps and meet people.

He dances so much nowadays that his mother, Regina Edwards, softly chuckles at how her son -- after a childhood of disability, social isolation and almost constant, excruciating pain -- sometimes doesn't get home until 2 or 3 in the morning.

After all, at age 22, Cain is making up for lost time.

"I feel like a new person," he says, "like I've got my life back."

It wasn't long ago that Cain's body was like a creaky old machine, breaking down one part at a time. First his toes balled up and froze in a bent position, then his knees failed and finally a hip and later a shoulder went out.

By the time he was a teenager, Cain was wheelchair-bound and unable to raise his arms.

The source of his trouble was an unusually aggressive and severe form of juvenile rheumatoid arthritis -- the worst case any of his doctors had ever seen. It had been coursing through his body since early childhood, attacking and destroying one joint after another.

"They (doctors) kept asking me, 'Is there anyone else in my family with it?'" said his mother. "No, he just popped up with it."

But now, the Hickory Hill resident is not only walking and dancing, but pursuing dreams of becoming a chef. He's living more of a normal life, thanks to a series of unusually complex surgeries.

During the past three and a half years, Cain has had his toes reconstructed and undergone operations to replace both knees, his right hip and, just last month, his right shoulder.

"We're hoping this is our last surgery," said Edwards.

The disease plaguing Cain is usually associated with middle or old age. But arthritis also is a pervasive childhood affliction that currently affects some 294,000 American kids under age 18, according to the Arthritis Foundation.

Rheumatoid arthritis, characterized by the inflammation of the lining of the joints, is one of the more common forms of juvenile arthritis. With no known cause or cure, it's an auto-immune disease that sometimes causes only mild problems, but often wreaks painful, life-changing damage by destroying joints and organs.

"Craig is truly a severe case," said Dr. Tim Krahn, an orthopedic surgeon with OrthoMemphis who operated on him.

"You don't normally see 21-22-year-old kids coming in with all their joints worn out."

Cain's journey, Krahn says, "is an amazing story."

It's one that can be traced to a small town outside Richmond, Va., where Cain and his family lived when he was a small child.

"Up until age 5, we had no problems," his mother said.

Cain has two older brothers who don't suffer from arthritis and are in good health. The first sign of his trouble was a rash on his knees, wrist and back. Then came the pain: lacerating jabs that could leave him screaming and crying at night.

A chronic fever made the ailment all the more mysterious.

For Edwards, the symptoms evoked fears that her son had multiple sclerosis, a disease that had killed her mother. But even after rheumatoid arthritis was identified as the ailment, doctors were flummoxed as to how to treat it.

"It seemed like anything that was supposed to work, it wasn't working for him," she said.

Casting around for solutions, doctors at a Richmond hospital planned to inject Cain with gold salts -- a well-established treatment that can reduce inflammation. But Edwards, a licensed practical nurse, researched the injections and vetoed them on the grounds that he was too young.

Dissatisfied with the treatment her son was receiving, she looked for a longer-term solution.

"I asked the doctor, 'Is there somewhere else where we could go for better medical treatment?'"

There was, came the answer. And the place? Memphis.

It was the reputation of the rheumatology specialists associated with Le Bonheur Children's Medical Center that prompted the Virginia doctors to refer Edwards to Memphis. She moved here with her sons in 1995.

Instead of the injections, doctors in Memphis tried gold pills. They worked for a while, Edwards said, but the disease continued to progress to the point that Social Security approved Craig's disabled status.

After years of walking with splints and braces, and undergoing painful physical therapy, he was limited to a wheelchair. The affliction had stolen any chance for a normal childhood.

"I couldn't go play sports, go out and have fun," he recalls. "I would basically sit in the house."

As the pain in Cain's knees and other joints grew worse, side effects of the disease took hold. Fluid build-up around his heart and lungs prompted a stay at St. Francis Hospital.

"He's had so many complications from that arthritis," Edwards said.

Cain's life soon revolved around a regimen of injections, pills and skin patches that delivered doses of everything from pain-killers to steriods. The treatments often made him nauseous, sleepy or depressed.

His graduation from Ridgeway High School in 2005 was a major achievement, but it also created a huge void in his life. Cain's friends were moving on, but, unable to get out and function, he was left behind.

"It was very depressing," he recalls. "I felt like I was in prison."

In an effort to cheer him up, Cain's mother bought him a dog, a Boston terrier, and arranged for him to get counseling.

But after nearly 15 years of dealing with the ravages of the disease, Cain was ready for a long-term solution. In subsequent visits to doctors, X-rays showed a total absence of cartilage in his knees -- just bone grinding on bone.

The operations to replace the knees would be anything but ordinary, however. The disease had been so severe that Cain's bone structure didn't develop normally, Krahn said.

"In Craig's case, the anatomy was very distorted."

But a new pre-operative navigation system developed by nearby Wright Medical Group provides doctors customized "cutting guides" based on CT or MRI scans. It helps ensure the implants are aligned correctly.

With his surgeries over -- assuming other joints won't need replacing -- Cain is now getting ready to learn how to drive. Then he wants to attend culinary school to learn to be a chef.

His mother, meantime, is enjoying freedom, too, now that she doesn't have to constantly care for Cain and take him to doctors. When reached by phone earlier this month, she was in Florida.

"I finally can go away and know that he's OK," Edwards says.

Cain still needs physical therapy, but he speaks like someone who has undergone a rebirth.

"That's what it feels like -- a second chance," he says.

Photo by Brandon Dill // Buy this photo

Rheumatoid arthritis sufferer Craig Cain has his shoulder stretched by physical therapist Sara Siler after his most recent of several surgeries in the last three and a half years. In addition to the shoulder surgery, he's had his toes reconstructed and had operations to replace both knees.

Now that he can walk, Craig Cain just wants to dance.

He danced on New Year's Eve, testing his reconstructed toes and two knee replacements by climbing stairs in Beale Street establishments that would've been impassable only months before.

Photo by Karen Pulfer Focht
Buy this photo »

Cain has spent most of his life bound to a wheelchair, but he recently began walking after having both of his knees replaced.

Photo by Karen Pulfer Focht
Buy this photo »

Regina Edwards moved her son, Craig Cain, to Memphis in 1995 because he needed special medical attention for his rheumatoid arthritis.

He danced at other clubs across Memphis, gradually building the confidence to try some tentative steps and meet people.

He dances so much nowadays that his mother, Regina Edwards, softly chuckles at how her son -- after a childhood of disability, social isolation and almost constant, excruciating pain -- sometimes doesn't get home until 2 or 3 in the morning.

After all, at age 22, Cain is making up for lost time.

"I feel like a new person," he says, "like I've got my life back."

It wasn't long ago that Cain's body was like a creaky old machine, breaking down one part at a time. First his toes balled up and froze in a bent position, then his knees failed and finally a hip and later a shoulder went out.

By the time he was a teenager, Cain was wheelchair-bound and unable to raise his arms.

The source of his trouble was an unusually aggressive and severe form of juvenile rheumatoid arthritis -- the worst case any of his doctors had ever seen. It had been coursing through his body since early childhood, attacking and destroying one joint after another.

"They (doctors) kept asking me, 'Is there anyone else in my family with it?'" said his mother. "No, he just popped up with it."

But now, the Hickory Hill resident is not only walking and dancing, but pursuing dreams of becoming a chef. He's living more of a normal life, thanks to a series of unusually complex surgeries.

During the past three and a half years, Cain has had his toes reconstructed and undergone operations to replace both knees, his right hip and, just last month, his right shoulder.

"We're hoping this is our last surgery," said Edwards.

The disease plaguing Cain is usually associated with middle or old age. But arthritis also is a pervasive childhood affliction that currently affects some 294,000 American kids under age 18, according to the Arthritis Foundation.

Rheumatoid arthritis, characterized by the inflammation of the lining of the joints, is one of the more common forms of juvenile arthritis. With no known cause or cure, it's an auto-immune disease that sometimes causes only mild problems, but often wreaks painful, life-changing damage by destroying joints and organs.

"Craig is truly a severe case," said Dr. Tim Krahn, an orthopedic surgeon with OrthoMemphis who operated on him.

"You don't normally see 21-22-year-old kids coming in with all their joints worn out."

Cain's journey, Krahn says, "is an amazing story."

It's one that can be traced to a small town outside Richmond, Va., where Cain and his family lived when he was a small child.

"Up until age 5, we had no problems," his mother said.

Cain has two older brothers who don't suffer from arthritis and are in good health. The first sign of his trouble was a rash on his knees, wrist and back. Then came the pain: lacerating jabs that could leave him screaming and crying at night.

A chronic fever made the ailment all the more mysterious.

For Edwards, the symptoms evoked fears that her son had multiple sclerosis, a disease that had killed her mother. But even after rheumatoid arthritis was identified as the ailment, doctors were flummoxed as to how to treat it.

"It seemed like anything that was supposed to work, it wasn't working for him," she said.

Casting around for solutions, doctors at a Richmond hospital planned to inject Cain with gold salts -- a well-established treatment that can reduce inflammation. But Edwards, a licensed practical nurse, researched the injections and vetoed them on the grounds that he was too young.

Dissatisfied with the treatment her son was receiving, she looked for a longer-term solution.

"I asked the doctor, 'Is there somewhere else where we could go for better medical treatment?'"

There was, came the answer. And the place? Memphis.

It was the reputation of the rheumatology specialists associated with Le Bonheur Children's Medical Center that prompted the Virginia doctors to refer Edwards to Memphis. She moved here with her sons in 1995.

Instead of the injections, doctors in Memphis tried gold pills. They worked for a while, Edwards said, but the disease continued to progress to the point that Social Security approved Craig's disabled status.

After years of walking with splints and braces, and undergoing painful physical therapy, he was limited to a wheelchair. The affliction had stolen any chance for a normal childhood.

"I couldn't go play sports, go out and have fun," he recalls. "I would basically sit in the house."

As the pain in Cain's knees and other joints grew worse, side effects of the disease took hold. Fluid build-up around his heart and lungs prompted a stay at St. Francis Hospital.

"He's had so many complications from that arthritis," Edwards said.

Cain's life soon revolved around a regimen of injections, pills and skin patches that delivered doses of everything from pain-killers to steriods. The treatments often made him nauseous, sleepy or depressed.

His graduation from Ridgeway High School in 2005 was a major achievement, but it also created a huge void in his life. Cain's friends were moving on, but, unable to get out and function, he was left behind.

"It was very depressing," he recalls. "I felt like I was in prison."

In an effort to cheer him up, Cain's mother bought him a dog, a Boston terrier, and arranged for him to get counseling.

But after nearly 15 years of dealing with the ravages of the disease, Cain was ready for a long-term solution. In subsequent visits to doctors, X-rays showed a total absence of cartilage in his knees -- just bone grinding on bone.

The operations to replace the knees would be anything but ordinary, however. The disease had been so severe that Cain's bone structure didn't develop normally, Krahn said.

"In Craig's case, the anatomy was very distorted."

But a new pre-operative navigation system developed by nearby Wright Medical Group provides doctors customized "cutting guides" based on CT or MRI scans. It helps ensure the implants are aligned correctly.

With his surgeries over -- assuming other joints won't need replacing -- Cain is now getting ready to learn how to drive. Then he wants to attend culinary school to learn to be a chef.

His mother, meantime, is enjoying freedom, too, now that she doesn't have to constantly care for Cain and take him to doctors. When reached by phone earlier this month, she was in Florida.

"I finally can go away and know that he's OK," Edwards says.

Cain still needs physical therapy, but he speaks like someone who has undergone a rebirth.

"That's what it feels like -- a second chance," he says.

Scruggs is the new Director of the Sports Medicine Outreach Program at OrthoMemphis, which launched in June 2009.  He and Emmons will serve as the Athletic Trainers for Christian Brothers High School.  Dabbs will work as the Athletic Trainer at Evangelical Christian School.

Scruggs received a degree in Exercise Science from the University of Memphis and became a Certified Athletic Trainer and a Certified Strength and Conditioning Specialist in 1996.  He has worked as an Athletic Trainer at Christian Brothers High School for over 11 years.

Emmons graduated from the University of Florida with a degree in Applied Physiology and Kinesiology with a specialization in Athletic Training and then received his Masters degree from Oklahoma University.  He previously worked with another local orthopaedic group providing outreach to Memphis University School.

Dabbs received his degree in Athletic Training from the University of Tennessee at Martin and his certification in Athletic Training from the Campbell Clinic.  He has worked as an Athletic Trainer at Evangelical Christian School for over six years.

OrthoMemphis physicians have provided Sports Medicine Outreach physician services for these schools, White Station High School and Collierville High School.

Temme is the Rehabilitation Director at OrthoMemphis where he has worked since 1998.  He has also completed the McKenzie Diploma and is Board Certified as an Orthopaedic Physical Therapy Specialist.  James joined OrthoMemphis in 2005 after receiving a Masters in Physical Therapy from the University of Tennessee.  Malone earned her Masters in Physical Therapy from UT Memphis and joined OrthoMemphis in 2003.  She also received McKenzie Certification.  With this new certification, the Physical Therapists will now have the designation CMP (Certified Mulligan Practitioner) after their names.

By passing the examination, Physical Therapists become certified in the concept of mobilizations with movement (MWMS) in the extremities and sustained natural apophyseal glides (SNAGS) in the spine through physical therapist-applied passive physiological movements and accessory techniques.

I have had the distinct honor of being a member of an extraordinary orthopaedic community.  The citizens of the Mid-South are indeed fortunate to have access to the orthpaedic clinical expertise available in the Memphis area.

Paralleling the abundance of orthopaedic clinical resources is a strong orthopaedic device industry.  While many of our citizens are aware of the importance of the MId-South as a distribution hub, far fewer realize the community contribution of our orthopaedic device industry.  I marvel at the array of resources present in Memphis, including their influence on industry, academia, logistics and their effect on finance, education and employment.  However, I have also recognized that for all of Memphis' strengths, we have not yet fulfilled the same potential in terms of orthopaedic clinical research.

On the scene comes InMotion Orthopaedic Research Center with exciting development potential.  Through the future-minded thinking of Memphis Tomorrow and the Memphis Bioworks Foundation, a special clinical research facility was crafted.  The independent research institute focuses solely on musculoskeletal research with the specific intent of "translational medicine," that is, moving research from basic "bench top" to "bedside" medicine.  The interface of clinical and applied basic science is essential in my view to create new and improved treatments for musculoskeletal disease.

The commonplace surgical procedures and devices that benefit patients today were initially a simple "concept" in the mind of a clinician with the need to improve treatment of a vexing clinical condition.  The busy clinician generally does not have the opportunity to "go to the workshop" and produce a new medical device.  The interface between the clinician and the finished clinical tool is complex and expensive to negotiate.  InMotion provides a "one-stop shop" to facilitate new orthopaedic tools.

Few communities possess the requisite research resources to facilitate this kind of clinical development.  Fortunately, at InMotion those resources are in place.  Collaboration between clinicians and industry is essential to the orderly development of life- and limb-saving procedures of the future.

InMotion employs a full team of clinicial research associates, including three registered nurses, who support clinical research science throughout the city of Memphis and its hospitals.  Their clinical research allows evaluation of new and improved treatment  in a diverse patient population and under a variety of clinical states over time.  It is through prospective research that meaningful, valid scientific discoveries are made and new treatments are developed.

InMotion's basic laboratory scientists also help orthopaedic surgeons study the effects that treatments can have on the human body over the long term.  For example, together we can analyze how a particular knee implant may change the cellular structure of bone, muscle and tendon, and its potential effect on tissues in adjacent regions of the body.

This informative dialogue can flow in both directions.  Those in my profession can also function to inform the clinical and basic science researchers at InMotion about specific clinical problems.  As an orthopaedic surgeon, I see treatment challenges my patients and colleagues face on a daily basis.  As such, we can partner with the InMotion staff and develop the best opportunities for research and collaborate in all aspects of the requisite science from basic to applied.

Besides the possibility of improving the community through the provision of "high tech" employment opportunities, the work of InMotion will certainly improve quality of life by development of new, effective treatments for musculoskeletal disorders.  We at Orthomemphis salute InMotion and look forward to research partnerships in the future.

Randall L. Holcomb, M.D. is the President of OrthoMemphis, a division of MSK Group, P.C.

For Halloran, president of the Orpheum Theatre, that was the turning point.  In December, he had a total knee replacement, and it has made a world of difference.  Halloran, like most people, had dealt with knee pain for years, which progressively got worse.  His employees became worried after seeing him hobble around the office everyday.  "It was really bothering me.  I had to give up golf," he recalled.  "I limped and could barely get out of my chair."  With his busy schedule at the office and going back and forth to New York each month, he didn't have a choice; he had to be able to walk.

The typical candidate for knee replacement surgery is someone with severe osteoarthritis.  Osteoarthritis is a progressive condition of cartilage degeneration in the joints.  The cartilage between the bones breaks down until it rubs against each other, resulting in damage to the tissue and underlying bone.  Symptoms include joint pain, stiffness after inactivity and limited motion.

Usually knee replacement surgery is a last resort until other treatments are exhausted.  Halloran tried all the alternatives to no avail, from cortisone shots to hyaluronic acid injections, a synthetic form of human joint fluid.  "After having a few X-rays, you could see it was bone on bone," he said.  Being a football player and golfer in high school, along with being heavy, contributed to the breakdown of his knee, Halloran conceded.

If modifying daily activities and different therapies fail to improve the joint, the options dwindle, explains Tim Krahn, M.D., orthopedic surgeon at OrthoMemphis, who performed Halloran's surgery.  He does about 10 to 15 knee replacements per month.  "When it gets to the point that the medications and injections aren't working, the quality of life is to where you're not walking, there are two options: learn to live with it and give up aspects of your life like walking and exercising, or take time out of your busy life and do a knee replacement," he explained.

Knee replacement surgery, also known as total knee arthroplasty, can help relieve pain and restore function in diseased knee joints.  As explained by Revolution-Health.com, total knee replacement involves surgery to cover ends of the damaged thighbone, lower leg bone, and usually the kneecap, with artificial surfaces lined with metal and plastic.  Doctors usually use cement to secure knee joint components to the bones.  The procedure takes about two hours and a patient's average hospital stay is three days.

"We encourage people to try everything short of surgery," Krahn said.  "Patients feel more comfortable with their decision if they've exhausted all the non-surgical approaches."

These days the surgery doesn't keep people down very long.  Depending on their fitness level, and most importantly their attitude, patients can function rather quickly.  One day after surgery, most people start to walk with a walker or crutches.  They can begin to resume climbing stairs, sitting in and rising from chairs, and other daily activities within a few days.  Doctors may recommend patients ride a stationary bicycle to strengthen their leg muscles and improve the ability to bend their knee.

"Pat amazed me with his progress," said Krahn.  "Pat was very motivated and worked.  He was out doing things quicker than the average person."  Most studies show that total knees have a 90 percent survivorship at 15 years.  Overall, the benefits outweigh the challenges; however, a small percentile may still have limited range of motion.

A couple weeks after his surgery, Halloran took a trip to Florida and walked around with a cane; two weeks later he was in New York.  Currently he has about 85 percent range of motion back in his knee.  Krahn says it takes about nine months to get back to 100 percent. 

To keep in shape, Halloran began with walking and using the elliptical machine and recumbent bike four times a week.  He admits he's let it go a little since the surgery, but he has new inspiration.  "I can tell it's been getting a little stiffer because I have been preoccupied, but I am getting back on it," he said.

Krahn maintained that people shouldn't make assumptions when it comes to replacement surgery, especially about whether they are too old or young for the surgery.  His 70- to 85-year-old patients think there's no point, but he asks them, "Do you want to live the next 10 years of your life as an 80- or 90-year-old person not being able to walk, or do you want to take two to three months and consider a knee replacement?"

While the average age of people undergoing replacement surgery is between 60 and 70, there are some younger people getting replacements, such as age 50 and even younger.  "As our society has gotten more active in older age, patients expect more out of their lifestyle," said Krahn.  "Surgical technique and instrumentation, pain management, accelerated rehab - all these things have combined to give people a better experience and outcome in a more predictable way."

As for Halloran, who was off to New York at press time to watch a series of Broadway shows for the Tony voting season, he hasn't looked back since the operation.  "My advice would be, and I'm not a doctor, wait as long as you can, but don't be miserable," he said.  "If your doctor says it's fine to do it, just do it."

Ken Beasley, CEO, OrthoMemphis PC

OrthoMemphis has historically embraced several key tenets, which should continue to produce positive outcomes during this time of uncertainty. Stay close to your customers and partners. We have developed a program to see patients in the office with acute injuries typically within 24 hours. Innovate and invest prudently. We have deployed technology, such as a hybrid electronic medical record and filmless X-ray system. Know and protect your core business. We focus on our conservative and cost-effective approach to the care of patients through the development and refinement of non-surgical treatment such as physical therapy services, non-operative back treatment and other, less-invasive and costly approaches. Consider strategic relationships. In May, 2008, OrthoMemphis merged with Tabor Orthopedics and will merge with Memphis Orthopaedic Group this summer.

The Arthritis Foundation, Memphis Area office, will host its annual Tribute Dinner Gala on Friday, April 11th, 6:30 pm at The Peabody Hotel. This year’s honorees are Dr. Shirley Raines, president of the University of Memphis and influential figure in the Memphis community; and OrthoMemphis, P.C., which has provided comprehensive, personalized orthopaedic care to arthritis patients since 1969.

The Arthritis Foundation’s Annual Tribute Dinner recognizes outstanding community members who exhibit strong leadership and make significant changes to better Memphis and its organizations. Whether significantly helping in the fight against arthritis or striving to make a difference in the community at large, the honorees have clearly dedicated themselves to further advancing and improving the city. By honoring these esteemed Memphians, this dinner works to raise funds for the numerous programs and services that the Arthritis Foundation conducts throughout the year. Recent honorees include, University of Memphis Head Basketball Coach John Calipari, Smith & Nephew and Dr. Scott Morris.

“We are thrilled to recognize this year’s guests of honor, Dr. Raines and OrthoMemphis, , for their ongoing commitment to bettering our community,” said co-chair Charles Burkett. “Gary Shorb and I both believe this is such a terrific event to be a part of since it not only raises money for a worthwhile organization, but in the process recognizes community members that have devoted their work and lives to improving Memphis.”

The Arthritis Foundation will also present one special person with its esteemed Volunteer of the Year Award at the Annual Tribute Dinner Gala Friday evening.

About the Arthritis Foundation

The mission of the Arthritis Foundation is to improve lives through leadership in the prevention, control and cure of arthritis and related diseases. Visit www.arthritis.org or call 901.685.9060.

"Bone cancer survivors like Emily Land are on the move again, thanks to new limb-sparing advances."

Emily Land and Ashley Garrett never knew each other growing up, but they have a lot in common.  For one thing, they lived just four miles apart in Collierville, Tennessee, a suburb of 47,000, complete with a Target, Chick-fil-A and eight public schools.  Both love sports: Emily, 24, was a Division 1 soccer player, and 15-year-old Ashley, an accomplished gymnast and cheerleader.  Each is a long-haired, fresh-faced beauty with impeccable Southern manners.  And then there are the scars, long and deliberate, snaking down each young woman's athletic left leg.  The marks are so striking that when Emily wears a skirt out to dinner with her husband, Chris, or Ashley attends a high school basketball game in her cheerleading uniform, strangers often ask, "What happened to your leg?"  "Shark attack," Emily sometimes answers.  "But you ought to see the shark!"  This isn't what really happened to either Emily or Ashley.  For those who are genuinely concerned, Emily might fess up and say, "I had cancer."  If she thinks her story could help someone else, she may reveal how a bone-eating tumor forced doctors to remove half her thighbone and replace it with a revolutionary metal implant that functions like real bone.  Thanks to the implant, Emily's left leg can move just like the other.  Emily was a college sophomore when she found her tumor in April 2003, and started chemotherapy followed by the surgery and more chemo, at St. Jude Children's Research Hospital in Memphis.  Ashley was only ten, in August 2002, when St. Jude doctors replaced her diseased shinbone with an artificial one.  As extraordinary as these state-of-the-art limb-sparing technologies are, perhaps the most remarkable thing is that, except for the young women's scars, no one watching as they walk or climb stairs would ever guess their secret.  Decades ago, a diagnosis of osteosarcoma meant amputation and often death.  Patients were sent home with a 20 percent chance of surviving five years.  The development of chemo in the 1970s markedly improved survival rates.  Because of huge advances in research and treatment of pediatric cancers at centers such as St. Jude, the chances of a child's beating the disease are now 75 percent over five years.  And high-tech bone replacements like Emily's and Ashley's are improving mobility for survivors.  Ashley's parents, Donna and Floyd Garrett, didn't know what to expect when Michael Neel, MD, an orthopedic surgeon at St. Jude, pointed to the X-ray and told them there was a good chance the strange bump that seemed to appear overnight on their little girl's leg was cancer.  Ashley could barely grasp the implication of the doctor's words.  "We don't know what this is right now, but whatever it is, Ashley, we're going to take good care of you," Dr. Neel said.  Scans and a biopsy indicated that the egg-size tumor had not spread.  But Ashley would still need three months of chemotherapy to kill any wandering cells and to shrink the tumor before Dr. Neel could remove it.  Dr. Neel said it was very lucky that Ashley's leg, severely weakened from the tumor, hadn't fractured during gymnastics or a recent family ski trip.  The mass would have ruptured, making the tumor grow larger.  Donna Garrett was even more shocked when Dr. Neel said he'd have to remove the upper third of Ashley's shinbone.  "We were prepared to do whatever it took to save her life," Donna recalls, "but I was concerned about how this would affect gymnastics and things she loves to do. How was she going to be a normal little girl?"  To get a safe margin around the tumor, Dr. Neel would also have to remove the growth plate at the base of Ashley's knee.  This plate, the source of new bone cells, was responsible for about 40 percent of the growth of her leg.  Ashley still had five more years and five inches of growth left.  So the surgeon planned to use a new implant called the Repiphysis – a bionic bone of sorts that expands when activated by an electromagnetic device.  It was a huge improvement over the previous generation of kids' prostheses, which were lengthened manually by reopening the surgical incision and turning a screw to expand the leg.  The Repiphysis would require just one surgery and several noninvasive lengthening sessions every year or so.  After an initial recovery period, including months of physical therapy, Ashley would be able to swim, ride a bike - even do some cheerleading.

On August 26, 2002, after four rounds of chemo, Ashley lay on a gurney.  In a pre-op room, surrounded by her family and pastor, they prayed and told Ashley angels were watching over her before heading to the waiting room to sit out the six-hour surgery.  Dr. Neel made an incision on the inside of Ashley's left leg, from above the knee joint to her ankle.  He and St. Jude's director of surgery, Bhaskar Rao, MD, carefully separated the muscles and blood vessels before sawing through her shinbone six inches above her ankle and lifting the diseased bone out of its socket.  Then he replaced it with the three sections of the Repiphysis.   First, he attached a titanium-alloy rod to the remaining shinbone.  Next he anchored the other end of the implant to the bottom of Ashley's thighbone.  Then he attached the midsection containing the expanding part and joined the pieces together by inserting at the knee a pin that acts like a hinge.  The surgery and the prosthesis would normally cost over $100,000.  But St. Jude operates entirely on donations, and treats and houses all children who meet certain medical requirements and their families, regardless of income, for free.  High-tech medical innovations are not foolproof, and sometimes there are complications.  That's what happened to Emily.  Since the 20-year-old midfielder for the University of Tennessee at Martin was full grown, Dr. Neel gave her a permanent, nonexpendable implant called the Guardian.  The surgery went well.  But a month afterward, she started experiencing pain and lack of muscle control.  "Every single step hurt like a screwdriver jamming up inside my bone," she said.  During a trip to Hawaii with a girlfriend, an end of chemo gift from her mother, Emily was so unsteady that she frequently got caught rolling in the surf and her friend had to grab her healthy leg to drag her back to shore.  Emily limped down the aisle at her wedding in April 2006 and hobbled through her honeymoon at Disney World.  In June 2006, Dr. Neel operated again.  When he cut into Emily's leg, he saw that the upper rod was spinning inside her thighbone.  It had never grafted to the implant.  He replaced and secured the rod.  Six weeks later, after just two weeks of physical therapy, Emily put her crutches down and walked away.  Her limp and the pain were gone.  In addition to getting regular checkups, Ashley went back to St. Jude every time her healthy leg grew more than a centimeter, about once a year, to have her implant lengthened.  First, Dr. Neel slipped a large magnetized ring, attached by a cord to a control box, around her leg so it circled the part of the implant that held a plastic-encased metal spring.  He pushed a button on the control box, sending a signal to an antenna in the plastic.  The plastic heated up and softened, allowing the spring to expand.  When an X-ray showed the spring had expanded to the desired length, a maximum of two centimeters at a time, Dr. Neel flicked the device off and the plastic hardened to freeze the spring in place.  Last April, an X-ray revealed that the growth plate in Ashley's right leg had closed.  Now that the young woman had reached her final height of five feet, two inches, it was time for Dr. Neel to replace the Repiphysis with the stronger, more permanent Guardian.  Ashley won't need a new rod until she's 25 or so.  Two weeks after the second surgery, I5-year-old Ashley, wearing a leg brace and on crutches, was back to enjoying get-togethers with her friends.  She and her brother, Tyler, were even planning a dinner party for their parents' 21st anniversary.  The one thing Ashley, Emily, and other implant recipients cannot do is high-impact sports, which could break the implant or surrounding bone.  "At first I was crushed I wouldn't be able to cheer in a competition," says Ashley.  "I asked God a lot, Why me?  But I've learned over the years there's a reason why I went through this."  She was back in her cheerleading uniform, on the less rigorous spirit squad, last fall and is practicing for her driver's license exam in January.  Donna Garrett feels her daughter has been given way more than what cancer took away.  She says Ashley was always kind but is even more compassionate now, an observation she made when Ashley's three-month-old cousin died from a heart defect in 2003.  "Ashley would tell her aunt that we're going to get through this, that we all have a purpose," Donna recalls.  "When Ashley's friends call to complain about boys, she tells them it's not a big deal in the scheme of things.  Her priorities are much different from those of a lot of other teenagers."  For Emily, the sacrifices have been harder to swallow.  While she's grateful to be able to hike, garden, and work out on the treadmill, what she really wants to do is take off on a full-speed run.  "I want to feel the wind in my face and get my heart rate up like I used to when I was on the soccer field," she says, sitting on the couch of her home in Cordova, with her dachshund mix, Molly, asleep at her feet.  "It's a harsh realization because I used to be 130 pounds of solid muscle. Now I'm much curvier and not much muscle."  A small price to pay.  The long process of becoming a cancer survivor, she says, has allowed her to become something else.

When she returned to college after her treatment, forced to leave soccer behind, Emily's grades soared.  She graduated summa cum laude in December 2005.  And the experience has brought her and Chris, who started dating as teenagers and are expecting a baby in May, much closer.  "When we first met, hugging was awkward for him.  After I got sick, he had to learn to hold me and make it okay.  And he can even deal with throw-up now," Emily says.  "I always joke that cancer sucks, but a lot of really good things came out of it."