Back on Pointe
Packard Children's orthopedic surgery and pain management teams heal a ballerina's ankleFourteen-year-old ballerina Alaina Bopp knows exactly how she'll spend her December holidays. She will be rehearsing for the elite Youth America Grand Prix ballet competition on two strong, healthy ankles.
It's a big change from last year’s holiday season, when Alaina had to stop dancing after Packard Children's orthopedic surgeon James Gamble, MD, PhD, diagnosed a non-cancerous tumor eroding her right ankle bone. On December 26, 2009, instead of pulling on her pointe shoes, Alaina was being admitted to Packard Children's for surgery. She knew she would be away from ballet for eight months or more.
"It was devastating," said Alaina's mom, Patricia. "Dance is her life."
Fortunately, Gamble had the expertise to heal Alaina so that she could dance again. That started with finding the correct diagnosis.
In the fall of 2009, after Alaina broke her ankle for the fourth time, a physician at home in Fresno, Calif., said her ongoing ankle problems were due to os trigonum – a malformation in which the ankle has an extra, non-functional bit of bone. He proposed surgery to remove it.
Elliot Krane, MD, Alaina Bopp, and James Gamble, MD, PhD
"The moment I looked at her I knew she didn't have os trigonum, because I have os trigonum," Gamble said. "Hers didn't look even close."
Examining Alaina's X-rays and MRIs, Gamble suspected a completely different problem. He asked if she had ever had a fall that caused a big, noisy "pop."
Immediately, Alaina and Patricia remembered a 2007 dance competition. While she was warming up backstage, the toe of Alaina's ballet slipper snagged on the carpet. She fell hard, her foot bent awkwardly underneath her so that the top of her foot hit the ground. The force of the fall transferred through the foot bones toward her heel, snapping off the back section of her ankle bone.
"Everybody there heard the pop," Alaina recalled.
Because it was one of several ankle injuries Alaina had endured, and foot and ankle injuries are extremely common in ballet, she didn't think much of it. She spent six weeks in a walking cast and went back to dancing. She was becoming more serious about ballet: By 2009, she was so strong that she could attend summer school at the Kirov Academy of Ballet of Washington, D.C., dancing from 8 a.m. to 6 p.m., six days a week.
From the radiology images, however, Gamble could see that the old break of the ankle bone had not healed.
"The type of fracture she had in 2007 was extremely rare," he said, adding that the medical literature contains no such case reports in teens. Instead of healing, the site of the break formed a granuloma – a tumor made of cells that dissolve calcified bone. Normally, these cells work in harmony with cells that build new bone. In her condition, the balance was off, eroding Alaina's ankle.
In surgery, Gamble carefully removed about a quarter of Alaina's ankle bone, including the entire tumor. Krane administered the anesthesia and prescribed a "pain pouch" that delivered medications to Alaina's surgical site via catheter, allowing her to avoid the side effects of systemic pain drugs as she recovered.
"It's amazing – there's such a teamwork approach here," Patricia said of Packard Children's. "And as a parent, you're part of the team; you're not a bystander. Your child is included, too."
Alaina began 2010 with 12 weeks off her feet, progressing gradually from a cast to a walking boot and crutches. She was homeschooled while she healed, rejoining her classmates in April for the end of 8th grade.
During the summer, Alaina had physical therapy to rebuild the muscles around her ankle joint and get back in shape for dance. Then, she got some big news in August. Gamble gave her the OK to return to ballet – and go back to dancing on pointe.
Back at her old dance studio, Alaina auditioned for the elite teams she had danced with before her surgery.
"I was really nervous," she said, adding that all of her peers had continued to dance while she recuperated. "But I was very lucky – I made all the same teams." She's now in six ensembles for ballet, modern dance, hip hop and jazz, rehearsing 14 to 20 hours each week. This fall, she also made the cheerleading team and was elected homecoming princess at the high school where she is now a freshman.
Perhaps best of all, an X-ray in November showed that Alaina's right ankle bone has completely regenerated.
"The part that was eroded by the granulation tissue has re-formed," Gamble said. "Her examination is essentially normal."
Alaina will be returning to Packard Children's on Dec. 23 – this time for a much happier occasion. She plans a dance performance for children who are hospitalized over the holidays, giving them hope for their own recovery.
"Last Christmas, we were so scared of what this surgery would bring," Patricia said, recalling the family's worries about whether Alaina would be able to return to dance. "If Alaina’s dancing can inspire at least one child, and reassure their family, that with the right doctors, the right care and hard work, you can return to what you love, then perhaps she can give a gift similar to what the staff at Packard Children's gave us."