Case Report: Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability

Patient History and Presentation:

A 25 year-old male presented with a complaint of significant recurrent shoulder instability and severe glenoid bone loss. Imaging revealed significant (50 percent) glenoid bone loss (Figures 1, 2). The patient reported multiple, recurrent dislocations related to recreational athletic activity. He was otherwise physically healthy.

Osteochondral Glenoid Reconstruction

Treatment Approach:

April Armstrong, M.D., Penn State Hershey Bone and Joint Institute, says: “Given the patient’s young age, baseline high level of physical activity and overall good health and significant glenoid bone loss, glenoid reconstruction using a fresh distal tibia allograft was chosen. With significant bone loss, such as in these cases, other traditional reconstructive options are not feasible, including traditional open instability or arthroscopic instability repair. The latarjet reconstruction is an option if there is less than 30 percent glenoid bone loss. However, these larger bone loss cases require either an iliac crest bone graft or this newer approach. The fresh distal tibial allograft is a good option in that it also has articular cartilage, but we don’t have long-term data to know if this is truly a clinical advantage. For a very young, athletic patient, this seemed the most desirable solution.”

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Developing an Adult Stem Cell Treatment Option for Posterior Tibial Tendon Dysfunction

Most patients with posterior tibial tendon dysfunction (PTTD, “fallen arches”) delay seeking treatment until the disease has progressed and requires surgery. Currently, available surgical approaches do not attempt to repair the degenerated posterior tibial tendon, but instead try to reinforce it with tendon transfers or decrease the load on the tendon via osteotomy or arthrodesis. Umur Aydogan, M.D., Penn State Hershey Bone and Joint Institute, and colleagues are currently investigating a novel autologous tibial tendon-derived adult stem cell approach for repairing and healing the damaged tendon, which is the underlying cause of the deformity.¹

Encouraging results from an initial preclinical investigation were described in a presentation at the 2015 American Foot and Ankle Society’s Summer Meeting in California; it was chosen as a finalist for the L. Goldner Award for best basic science article. Dr. Aydogan explains, “We isolated tendon-specific stem cells from the posterior tibial tendons of three patients with PTTD who were undergoing surgical repair. After six weeks in co-culture with tendon pieces, the stem cells began to differentiate into tenocytes. At 10 weeks, the tenocyte colony began to exhibit tendon structure.” (Figure) Adult stem cell characteristics and chondrogenic differentiation were confirmed using a combination of gene expression analysis and immunocytochemistry. This is the first time that human tendon stem cells have been isolated and successfully cultured to differentiate into tenocytes, with the potential to form healthy tendon tissue. Continue reading

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Medial Patella Femoral Ligament (MPFL) Reconstruction for Patellofemoral Instability

Medial Patellofemoral Ligament - Figure 1

FIGURE 1. The medial patellofemoral ligament (MPFL, yellow arrow) is a very thin ligament approximately 6 cm long.

Acute, trauma-related patella dislocation is a common knee injury seen in the orthopaedic clinic, most often in young athletes or highly active pediatric patients. Although conservative, nonsurgical management of an initial patella dislocation yields excellent results in most cases, up to 50 percent of patients may experience a recurrence, marked by underlying MPFL laxity that requires repair and reconstruction.1,2

Wayne Sebastianelli, M.D., Kalenak Professor of Orthopaedics and associate dean for clinical affairs at Penn State College of Medicine University Park Regional Campus notes, “With a recurrent or non-healing patellar dislocation, it’s important to identify the extent of the ligament and bone injury to devise an effective reconstruction approach. Commonly, in most cases, the MPFL has been ruptured or damaged.” Continue reading

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Biomechanical Analysis to Guide Future Trends in Hip Replacement Surgery and Post-Operative Rehabilitation

Minimally invasive and traditional approaches to total hip arthroplasty yield positive outcomes for most patients six months following surgery. “Most of these patients are happy to simply walk well and experience less pain,” says John Nettrour, M.D., Penn State Hershey Bone and Joint Institute. Yet gait analysis research indicates that many hip replacement patients can be expected to exhibit continuing gait abnormalities that may limit daily function.¹ Following hip replacement, patients display diminished velocity, and stride length and an irregular cadence that can translate into a fall risk or limited ability to engage in daily physical activity, such as climbing or descending stairs.

Dr. Nettrour and other colleagues plan to use a new gait analysis and biomechanics laboratory recently established at Penn State Hershey Medical Center as an important tool to help patients normalize their gait following hip replacement surgery, improving long-term outcomes and daily function. Dr. Nettrour explains, “We’re interested in how variations in surgical technique may affect the recovery of a normal gait pattern over time. We hope approaches that minimize soft tissue injury can facilitate an easier recovery and ultimately yield better approximations of normal gait.” Continue reading

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Complex Limb Reconstruction Case Report: Combined Use of the Ilizarov Technique and Taylor Spatial Frame

Complex Limb Reconstruction Case PresentationSuccessful combined use of the Ilizarov technique and Taylor spatial frame spared a healthy mother of two from the amputation of her left leg (above the knee) following a traumatic accident; the team was able to save her knee and work to heal it before any amputation needed to occur. According to J. Spence Reid, M.D., trauma surgeon, Penn State Hershey Bone and Joint Institute, “An initial attempt to reconstruct the knee failed when massive infection developed. Debridement of infected tissue and bone resulted in large bone defects.” Reid and the patient discussed amputation versus preserving the limb. “As an active young woman, the patient and her family felt very strongly about trying to preserve the leg.” Thankfully there were options.Ilizarov technique and Taylor spatial frame

After enduring six months of the Ilizarov and Taylor spatial frame techniques, and eight surgeries in 12 months, including fusion of the knee and placement of an intermedullary nail, the bone defects have fully healed and the patient is able to walk and perform most normal daily activities with no pain or ambulatory aids. Reid adds, “This was a highly personal decision to undergo an arduous, painful, and expensive series of treatments. While this approach is not for everyone, the patient and her family are very satisfied with the outcome.” Continue reading

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Magnetically Controlled Growing Rod System Offers Nonsurgical Distraction for Early Onset Scoliosis

U.S. News & World Report Best Children's Hospital - Orthopedics, 2015-2016A magnetically controlled growing rod system (MAGnetic Expansion Control, MAGEC™) was approved by the United States Food and Drug Administration for treatment of early onset scoliosis in February 2014. Used in Europe since 2009, MAGEC provides a nonsurgical distraction alternative to conventional growing rod systems. Douglas Armstrong, M.D., Penn State Hershey Bone and Joint Institute, and chief of pediatric orthopaedics, Penn State Hershey Children’s Hospital, specializes in treating pediatric scoliosis, and welcomed the new device, explaining, “We currently have 11 patients who have a MAGEC system in place for treatment of early onset scoliosis. The expansion is performed in the clinic every three months, as an office visit.” Continue reading

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Pearls for Internal Distraction Plating of Complex Distal Radius Fractures

Distal radius fractures are the most common type of fracture treated in emergency departments. According to Alexander H. Payatakes, M.D., Penn State Hershey Bone and Joint Institute, “The vast majority of operative distal radius fractures can be successfully treated with a volar locking plate. However, standard volar locking plates don’t perform well when the fracture extends to the diaphysis or when there are grossly comminuted fragments too small to capture with screws. Adequate stability is especially important when the patient has also sustained lower extremity fractures that will require early loading of the wrist to ambulate with a walker or crutches.” Such fractures often occur in both older patients with osteopenia, as well as a result of motor vehicle accidents. Continue reading

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