Management of a Complex Open Pelvic Injury: A Coordinated Team Approach

A man in his forties was brought to the Penn State Hershey Medical Center trauma unit. The patient sustained an open pelvic fracture, as well as an irreducible hip dislocation; he had a significant injury to his lower intestinal tract and massive soft tissue loss.

“Open pelvic fractures have a mortality rate of 50 percent. If you combine this with the spectrum of additional injuries this patient presented with, that number is probably closer to 75 percent,” says Henry Boateng, M.D., an orthopaedic trauma surgeon with Penn State Hershey Bone and Joint Institute. A team of trauma, colorectal, orthopaedic, and plastic surgeons joined together to improve the odds for this patient. “For cases like this, we take a very aggressive approach, and prioritize the treatments needed. The goal in the early stages is to prevent infection and provide stability,” explains Boateng. The abdomen was emergently addressed, the hip was emergently reduced, and the pelvis was then stabilized. Continue reading

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Superior Labral Tears in Patients Older Than 40: What is the Best Treatment?

Intraoperative arthroscopic image of an acute, traumatic SLAP tear.

Intraoperative arthroscopic image of an acute, traumatic SLAP tear.

Superior labrum anterior-posterior (SLAP) repair in young athletes has a well-established record of success, marked by relief of pain, improved range of motion, and return to normal levels of activity. Over the past ten years, however, there has been a remarkable five-fold increase in SLAP repairs in older patients. According to Aman Dhawan, M.D., Penn State Hershey Bone and Joint Institute, “Recently there’s been a lot of controversy about performing arthroscopic SLAP repair in patients older than 40 years of age. I often see these older patients experience SLAP repair-related complications.” The SLAP repair literature is marked by conflicting reports, some showing very good outcomes and others describing poor outcomes in older patients. Continue reading

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Sarcopenia and Increased Body Fat in Sclerostin-deficient Mice: Interactions between Muscle and Bone and Potential Implications for Osteoporosis Management

In the absence of mechanical load (off-loading), as may occur following injury, bone and muscle tissue are lost, increasing the risk of low-impact bone fracture and musculoskeletal weakness and injury. Henry J. Donahue, Ph.D., Michael and Myrtle Baker Professor of Orthopaedics at Penn State College of Medicine, observes, “While bone loss following disuse is fairly well-understood, relatively little is known about how bone and muscle tissues interact during off-loading.”

Sclerostin [a glycoprotein encoded by the SOST gene that inhibits the Wnt signaling pathway], a key factor that mediates bone loss, exhibits increased expression by osteocytes during off-loading and inhibits bone formation by osteoblasts. Donahue, and anatomy graduate student Andrew Krause, along with Charles Lang, Ph.D., distinguished professor of cellular and molecular physiology, conducted an experiment in SOST-knockout mice, globally deficient in sclerostin, and subjected to off-loading, to examine effects on muscle tissue, as well as bone. Donahue explains, “In the SOST-knockout mice, as we predicted, trabecular bone loss from two weeks of off-loading was largely mitigated, compared to the loss seen in wild-type mice. What was interesting and unexpected was that at baseline, even though both groups of mice were of similar weight, the sclerostin-deficient mice had significantly less lean muscle tissue and more adipose tissue; off-loading led to further and dramatic loss of muscle [e.g., sarcopenia] and gain of fat.” (see figure)

Osteoporosis Management

Sclerostin-deficient mice (right) have bigger bone than normal wild type mice (left). However, muscle mass actually decreases in sclerostin-deficient mice.

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Advantages of Total Ankle Replacement versus Pantalar Arthrodesis

Ankle Replacement

A) Preoperative anteroposterior X-ray
B) Lateral postoperative anteroposterior X-ray
C) Lateral X-ray with replacement

Patients suffering from severe arthritis of the ankle or foot, or patients with pes planus, or “flat foot,” commonly undergo fusion of the hind-foot joints (triple arthrodesis). When successful, such arthrodeses can eliminate or substantially decrease pain associated with weight-bearing activities.

“Patients can expect almost normal activity following hind-foot arthrodesis, although side-to-side motion is limited,” explains Paul Juliano, M.D., chief of foot and ankle orthopaedics at Penn State Hershey Bone and Joint Institute. “A potential negative consequence of this procedure is that the joints above and below the fused area take extra stress, and as a result, arthritis can progress in the ankle and the mid-foot,” explains Juliano.

Pantalar arthrodesis (the addition of an ankle arthrodesis to a previously performed hind-foot arthrodesis) has been traditionally performed as a salvage procedure, to alleviate severe pain and stabilize an unstable ankle or foot. Juliano notes, however, “While the pantalar arthrodesis can alleviate pain, it leaves the patient with something very similar to a ‘peg-leg’, with no ability to flex the foot forward and back or side-to-side. Functionality is poor. One could also expect arthritis and pain to progress in the knee and hip.” Continue reading

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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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