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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Unique Challenges of Managing Injuries on the Sports Field

Scott Lynch, M.D.

IMAGE COURTESY OF JOE HERMITT, THE PATRIOT-NEWS.

Orthopaedists are on-site to manage injuries sustained during play and competition at many collegiate sporting events. With 17 years as a team physician, including the past two years for the Penn State Nittany Lions’ football team, Scott Lynch, M.D., Penn State Hershey Bone and Joint Institute, relays his unique perspective, “Dealing with injured athletes on the playing field is very different from being in the emergency room or clinic; imagine 107,000 people evaluating your performance.”

Privacy for athletes must be a priority, especially when there is media coverage of the event. “Many games are covered by the media, so I ask team support staff to form a circle around me and the injured player. It’s important to establish calm, especially because we need the patient to cooperate,” says Lynch.

Planning ahead is key, including knowing where athletes should be taken for different levels of injuries and the easiest path to the training room. He also recommends talking to the emergency medical services crew before the game, to know how to call them to the field and where to exit the stadium or building. Continue reading

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Community-based Heel Ultrasound Screening Leads to Osteoporosis Follow-up and Treatment Recommendations

“Providing calcaneal quantitative ultrasound (US) scanning as a free screening can be an effective strategy for improving osteoporosis detection and treatment,” says Edward Fox, M.D., Penn State Hershey Bone and Joint Institute. In a recent study of adults who received free calcaneal US screening at community health fairs and telephone follow-up, Fox, Frances Tepolt, M.D., and Susan Hassenbein, CCRP, demonstrated that nearly half of those identified as high-risk for osteoporosis (T-score less than or equal to -1) sought evaluation from a health care professional within three months. The large majority of these individuals also received recommendations for further bone density evaluation and treatment (Figure).

Heel Ultrasound ScreeningParticipants, none of which had ever had a fragility fracture, were also given access to informational pamphlets about bone health and osteoporosis. Fox emphasizes, “This study is among the first to examine individuals, access to osteoporosis screening results and disease information, prior to the occurrence of any overt signs of disease, like a fragility fracture. With about half of the high-risk individuals seeking follow-up, this study supports that heel US screening has the potential to increase osteoporosis diagnosis and intervention.” Continue reading

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Pigment Epithelium Derived Factor (PEDF) Influences Matrix Mineralization: Implications for Osteogenesis Imperfecta and Beyond

Patients with type VI Osteogenesis Imperfecta (OI) have mutations in the serpfin1 gene that lead to an absence of pigment epithelium derived factor (PEDF) production, and experience bone defects and frequent fracturing. A series of in vitro experiments performed by Feng Li, M.D., Ph.D., instructor, Penn State Hershey Orthopaedics and Rehabilitation, under the guidance of Christopher Niyibizi, Ph.D., are among the first to demonstrate a direct link between PEDF and a broad array of gene expression changes associated with increased osteoblast differentiation and matrix mineralization (Figure 1). The findings, recently published in Stem Cells¹ and Journal of Cellular Physiology², help to explain why patients with this rare subtype of OI experience bone fractures despite normal type 1 collagen expression and formation. The implications of the findings, however, extend to other conditions marked by decreased mineralization, like osteoporosis.

Osteogenesis Imperfecta (OI)

FIGURE 1. PEDF increases mineral deposition by mineralizing osteoblasts and suppresses sclerostin production by osteocytes. A) Osteoblasts were cultured in osteogenic medium in presence or absence of exogenous PEDF for twenty-one days. Analysis of mineral deposition by Alizarin red S staining (AR-S) showed increased mineral deposition in cultures supplemented with PEDF. B) Sclerostin production by osteocytes in mineralizing cultures was detected beginning at two weeks, and cultures supplemented with exogenous PEDF reduced production of sclerostin by osteocytes.

For the experiments, exogenous PEDF was added to the osteogenic culture medium of adult human mesenchymal stem cells, PEDF enhanced the cells’ differentiation and increased mineralization in vitro¹. According to Niyibizi, “Among the more pronounced effects of exogenous PEDF were the 70 to 75 percent reductions in sclerostin and matrix extracellular phosphoglycoprotein expression (MEPE) by osteocytes².” Sclerostin is a strong inhibitor of bone formation and MEPE inhibits matrix mineralization; with addition of PEDF to the mineralizing medium, matrix mineralization significantly increased, compared to cultures without exogenous PEDF. Continue reading

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Choosing Between Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: Patient Selection is the Key

Q: Is there a general consensus among orthopaedic surgeons about how best to choose between total hip arthroplasty (THA) versus hemiarthroplasty for their patients with femoral neck fractures?

Davis: No. There are conflicting opinions about which of these procedures is best suited to particular patients. Studies from individual centers tend to emphasize the improved functional outcomes in patients who have a THA, while national registry data tends to demonstrate the lower complication rate with hemiarthroplasty. The differences may relate to the patient populations in each study and the technical skills of the surgeons. Outcomes from each type of study are valuable. Surgeons and patients should balance the risks and benefits to determine the best approach for each individual patient.

Q: Based on your interpretation of the available registry data, what are the main advantages and disadvantages of THA?

Davis: Compared to hemiarthroplasty, THA yields better pain relief and patients are able to walk farther, on average. Disadvantages, however, include longer surgical time, increased dislocation risk, and potential for acetabular component loosening. Several countries have registry data that suggest rates of complications, including dislocation, are higher with THA versus hemiarthroplasty. Also in most hip fracture cases, the acetabular bone stock is softer and the acetabular fixation is less secure than in arthritic hips with denser bone. In my opinion, the literature supports THA as the procedure of choice for younger more active patients and those with pre-existing arthritis. (Figure 1)

Total Hip Arthroplasty (THA)

FIGURE 1A: Patient with femoral neck fracture for THA. FIGURE 1B: Patient X-ray after surgery. FIGURE 2: Appropriate candidate for hemiarthroplasty; 64-year-old man who fell on ice.

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