Costotransversectomy: An alternative surgical approach to challenging thoracic spine reconstructions

While open thoracotomy is the traditional approach most often chosen for patients undergoing thoracic spine reconstruction, alternative approaches can be useful in certain situations. Mark Knaub, M.D., Penn State Hershey Bone and Joint Institute, says, “For patients with spinal tumors, osteomyelitis or major trauma, particularly at upper thoracic levels, an open thoracotomy may not offer sufficient access to the surgical site. In these cases, a costotransversectomy approach can be superior. A single surgical approach can be used for both removal of diseased vertebral body tissue and placement of stabilizing hardware.” To minimize complications and optimize reconstruction, Knaub explains, “It’s critical to achieve the proper angle of access and for this it’s necessary to remove approximately five centimeters or more of at least two ribs; in some situations, more rib tissue must be removed. Such removal also involves sacrificing one or two thoracic nerve roots.” Because the nerve roots are sensory in nature and share overlapping fields of innervation, patients may experience postoperative numbness, but there are no functional consequences. There is a small risk of violation of the pleura, as well as major blood vessel injury. These risks can be minimized by staying right against the bone while working in the anterior column. Continue reading

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Targeted Ultrasound Screening for Developmental Dysplasia of the Hip: Where Do We Stand?

AP X-ray of pelvis in a six-week old child

AP X-ray of pelvis in a six-week old child

Developmental dysplasia of the hip (DDH), seen in 2 of every 1000 infants, is present when there is an abnormal relationship between the femoral head and acetabulum, including dislocation, partial-dislocation, and instability. William Hennrikus, M.D., Penn State Hershey Bone and Joint Institute, says, “It’s widely understood that early detection of DDH is important because, if untreated, it can lead to gait anomalies, pain, and arthritis. All babies are universally screened for DDH at well-baby visits using a physical examination. Infants born in the breech position and those with a family history of DDH, however, are at increased risk and require regular examination and monitoring.” Since 2000, the American Academy of Pediatrics (AAP) has recommended targeted hip imaging via ultrasound at six weeks of age for female infants born in the breech position, along with optional hip imaging for boys born in the breech position or girls with a positive family history of DDH [1,2]. Hennrikus notes, “The AAP recommendation assumes that ultrasound is universally available. Our research shows that in Pennsylvania this isn’t the case.” Continue reading

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Addressing the Technical Challenges of Reverse Total Shoulder Arthroplasty and Lowering the Risk of Complications

Reverse total shoulder replacement arthroplasty, a technically challenging surgery, is often reserved for patients with serious shoulder pathology that cannot be adequately addressed with more conventional procedures. In patients who present with a massive irreparable rotator cuff tear and arthritis, a reverse total shoulder replacement can dramatically restore function and reduce pain. In the past, there would have been few good options for helping these patients. Nevertheless, according to Hyun-Min (Mike) Kim, M.D., Penn State Hershey Bone and Joint Institute, “Complications are seen in approximately 10 percent of patients who have this procedure done; about half of all complications involve instability. Mechanical impingement between the components and native tissue can contribute to instability and later to scapular notching.” To improve outcomes for these patients, Kim takes specific intra- and post-operative steps aimed at reducing risk of instability. Continue reading

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Want to meet any of the Penn State Hershey Bone and Joint Institute faculty at upcoming orthopaedic conferences?

The following faculty members will present at state, national, and international conferences in 2014:

Kevin Black, M.D.
Frederick N. Myer, M.D., Keynote Speaker, 2014 American Association of Orthopaedic Surgeons Annual Meeting
March 12, 2014
New Orleans, Louisiana

William Hennrikus, M.D.
American Association of Orthopaedic Surgeons Annual Meeting
March 13, 2014
New Orleans, Louisiana

J. Spence Reid, M.D.
Limb Lengthening Meeting
March 14, 2014
New Orleans, Louisiana

Henry Boateng, M.D.
Pennsylvania Orthopaedic Society Spring Scientific Meeting
April 10, 2014
Hershey, Pennsylvania

Kenneth Taylor, M.D.
Pennsylvania Orthopaedic Society Spring Scientific Meeting
April 10, 2014
Hershey, Pennsylvania

Alexander Payatakes, M.D.
Pennsylvania Orthopaedic Society Spring Scientific Meeting
April 10, 2014
Hershey, Pennsylvania

Michael Darowish, M.D.
Pennsylvania Orthopaedic Society Spring Scientific Meeting
April 10, 2014
Hershey, Pennsylvania

William Hennrikus, M.D.
Orthopaedic Trauma Association Annual Trauma Course
April 18, 2014
Chicago, Illinois

J. Spence Reid, M.D.
Chilean Orthopaedic Trauma Society Meeting
April 2014
Chile

William Hennrikus, M.D.
Pediatric Orthopaedic Society of North America Annual Meeting
May 2, 2014
Los Angeles, California

William Hennrikus, M.D.
American Academy of Pediatrics Annual Meeting
October 13, 2014
San Diego, California

Kevin Black, M.D.
Course director, 47th Annual American Association of Orthopaedic Surgeons
Course for Orthopaedic Educators
November 2-6, 2014
Bloomingdale, Illinois

William Hennrikus, M.D.
International Pediatric Orthopaedic Society
December 5, 2014
Orlando, Florida

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Four-Year Study of MRI-Defined Hip Labral Tears in High-Level Ice Hockey Players

Ice hockey playerIn high-level athletes, joint pathology discovered on imaging studies is extremely common, even among those not manifesting clinical symptoms. Magnetic resonance imaging (MRI) studies of asymptomatic professional baseball pitchers show 79 percent with labral abnormalities in the shoulder;1 likewise, 65 percent of asymptomatic college basketball players show some combination of patellar tendinosis or chondrosis.2 Based on the abnormalities present on MRI, surgeons can potentially be misled into recommending a surgical procedure, based on an imaging finding, that does not correlate with clinical symptoms or physical exam. According to Robert A. Gallo, M.D., Penn State Hershey Bone and Joint Institute, “Arthroscopic repair of tendon or joint damage often requires recovery time of four to six months. In an average athlete with a playing career of five to six seasons, this downtime can have a significant impact on their career. Therefore, any decision to proceed with surgical intervention, especially hip arthroscopy, should be carefully considered.” Continue reading

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Achieving Success in Complex Nerve Repair of the Hand: A Lengthy Team Effort

Repair of damaged peripheral nerves, introduced some twenty-four centuries ago, continues to present opportunities and vexing challenges to surgeons and patients. Unlike neural tissue in the central nervous system, peripheral nerve fibers can regenerate, but achieving success is often a long road of healing, surgery, and occupational therapy. According to Kenneth Taylor, M.D., Penn State Hershey Bone and Joint Institute, “Nerve injury in the arms and hands may be associated with complex lacerations, machinery accidents, or automobile crashes. Life-threatening injuries need to be addressed first, and nerve repair is secondary, done sometimes weeks or months later.” More often, nerve repair can be done in the acute post-injury period.

“When there is a clean injury of a digital nerve, the transected fibers can be sutured together during primary treatment of the wound. Most patients will have a complete recovery,” notes Taylor. Many nerve injuries, however, are much more complex, with extensive damage to surrounding bone and soft tissue. Having formerly served in the military, Taylor gained experience carrying out some of the most complex nerve reconstruction procedures in veterans wounded in Iraq and Afghanistan. Continue reading

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Penn State Hershey Researchers Identify Stem Cells in Shoulder Bursa, Intend to Explore Use in Tendon Repair

Patients with rotator cuff tears usually seek treatment when shoulder pain disrupts sleep and quality-of-life and interferes with daily functions. Reaching above shoulder height or behind the back, lifting, or pulling may become painful, difficult or impossible. Such injuries are particularly common among older adults, according to April Armstrong, M.D., Penn State Hershey Bone and Joint Institute.

“The rotator cuff tissue is often in an age-related degenerative process and it doesn’t heal well in older adults. When an older patient experiences a tear, the chances of successful healing are low. With each decade of life, prognosis for healing worsens.” Larger tears are also associated with less success. To improve outcomes, Armstrong explains, “Surgeons have developed different strategies, such as injections of growth factors into the joint to spur healing, or plasma-rich proteins, which might act as a patch over the damaged tissue and encourage in-growth of healthy tissue.”

While studying as a travelling fellow in Europe, Armstrong noted that some older surgeons were careful to retain the bursa in rotator cuff repair, explaining that the bursa had ‘good stuff’ in it that encouraged healing. “This runs counter to the aggressive removal of the bursa that most surgeons carry out in rotator cuff repair,” notes Armstrong. She recognizes that retaining the bursa may be a useful strategy in some cases. “My travelling fellowship experience sparked a notion that the bursa might contain stem cells that could differentiate to form new tissue.” Continue reading

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