An “Old-Fashioned” Treatment Gains Modern Momentum: Serial Casting for Infantile Scoliosis

AP spine age  eight months

X-ray at eight months and 45 degree angle

Douglas Armstrong, M.D., Penn State Hershey Bone and Joint Institute, has taken a serious second look at serial casting for infantile scoliosis and found reason to pursue its use for his own patients. “Just ten years ago, the technique was largely rejected by U.S. physicians, who regarded it as ineffective. But patients with early onset scoliosis, meaning those who develop scoliosis before age five, face grim long-term outcomes if not treated.” Serial casting seemed to Armstrong a reasonable option.

“Many surgeons believe that infants with scoliosis onset don’t do well with brace treatment. Apart from casting, the only other option is surgical intervention,” explains Armstrong.

Inadequately corrected infantile scoliosis leads to chest wall deformities, poor lung development, and higher rate of early adulthood mortality; therefore, physicians have begun to use more aggressive treatment approaches. Typically, Armstrong and his Penn State Hershey colleagues may treat twelve or more cases of early onset scoliosis per year.

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Proof of Concept: Experimental Metatarsal osteotomy Leads to Greater Reduction in Plantar Pressure Versus Weil Osteotomy and its Modifications

For treating various conditions that result in metatarsalgia, the basic aim is to reduce load transmission through the operated metatarsal and reduce pressure on the plantar surface of the metatarsal. The classic Weil osteotomy, recommended for the subluxed or dislocated metatarsal phalangeal joint (MTPJ), is effective for reducing pain.

According to Umur Aydogan, M.D., Penn State Hershey Bone and Joint Institute, “Although Weil osteotomy can be effective, some patients experience complications, like recurrent or transfer metatarsalgia, ‘floating toe,’ avascular necrosis, and stiffness. Some complications may occur because this is an intra-articular procedure.”

Aydogan, along with biomechanical engineering colleagues at Penn State Hershey, has explored an alternative extra-articular procedure to reduce the high plantar pressure associated with metatarsalgia. In a cadaveric model, they compared the effects on plantar pressure following classic and modified Weil osteotomies versus their extra-articular, proximal metatarsal diaphyseal oblique dorsiflexion second metatarsal osteotomy. The findings will be presented at the upcoming annual meeting of the American Orthopedic Foot and Ankle Society (AOFAS).1

Biomechanical set up and osteotomy illustration

Biomechanical set up and osteotomy illustration

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Seventy-two-hour Protocol for Achieving Coverage of Complex, Open Fractures

Open fractures, usually resulting from automobile or motorcycle accidents, are often associated with poor long-term outcomes involving loss of function, amputation and mortality. “To preserve the limb, the most important goals are to stabilize the fracture, decontaminate the wound, and preserve or re-establish the blood supply,” explains Henry Boateng, M.D., Penn State Hershey Bone and Joint Institute. Continue reading

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Successful Repair of Osteochondritis Dissecans: Sometimes Less Is More

For osteochondritis dissecans (OCD) of the knee, avascular necrosis of subchondral bone can lead to fragmentation of bone and overlying cartilage [Figure 1]; osteochondral loose body formation may occur, leading to pain and further articular damage. According to Kevin Black, M.D., Penn State Hershey Bone and Joint Institute, “The number one goal in treating all patients with OCD is to preserve the articular surface. In skeletally immature children, OCD tends to heal on its own with three to six months of rest and limited activity. In skeletally mature patients, the lesions don’t heal and predictably require surgery.” Continue reading

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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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