Patellar instability, with repeated lateral dislocation, commonly seen in younger, active adults, is associated with a number of anatomical pathologies and usually requires surgical intervention. Among these, increased tibial tubercle to trochlear groove (TT-TG) distance is a prominent risk factor. TT-TG distance describes the degree of lateralization of the tibial tubercle. “TT-TG distance is routinely measured in most patients who present with a partial or complete knee-cap dislocation. This makes it an accessible piece of information that could potentially be used to identify patients at-risk for repeated dislocations,” explains Paul Sherbondy, M.D., Bone and Joint Institute.
Measurement of Tibial Tubercle to Trochlear Groove (TT-TG) Distance by MRI for Patellofemoral Instability
Novel Pin Array Guide Boosts Accuracy of Glenoid Component Positioning in Total Shoulder Arthroplasty
Achieving accurate glenoid component placement during total shoulder arthroplasty is one of the most challenging aspects of the procedure. In most cases, there is substantial arthritis-related bone deformity with limited exposure of the glenoid surface intra-operatively, making it difficult to visualize. April D. Armstrong, M.D., chief, shoulder and elbow surgery, Bone and Joint Institute, says, “When the glenoid component isn’t accurately placed, it tends to loosen and eventually requires a revision procedure.” Using traditional placement techniques in one investigation, errors in version and inclination of the central drill line, on average, were approximately 9 degrees and version error correlated with the degree of arthritic glenoid version.¹ Continue reading
One of the most challenging scenarios is the patient with a complex hindfoot deformity involving both the ankle and the subtalar joint. “Hindfoot deformities involve complex anatomy, and may be caused by trauma, arthritis, congenital disease or may be related to Charcot neuropathy,” explains Paul J. Juliano, M.D., chief, foot and ankle orthopaedics, Bone and Joint Institute. Tibiotalocalcaneal (TTC) arthrodesis, often paired with osteotomy, is a salvage procedure typically performed in patients with severe tibiotalar and subtalar arthropathy with a significant pre-operative deformity. Over the past 10 to 15 years, treatment has shifted away from external fixation to internal fusion achieved with an intra-medullary nail.1,2 Continue reading
In recent years, a resident and a medical student from Penn State College of Medicine have each won the American Academy of Pediatrics (AAP) Young Investigator Award for research, and have since published their findings in the Journal of Pediatric Orthopaedics. In 2014, fourth-year medical student, Matthew J. Pacana, won the AAP award for research regarding the use and outcomes associated with ultrasound (US) examination for hip dysplasia in infants born breech, despite a normal physical examination.¹ The work examined Penn State Health Milton S. Hershey Medical Center’s implementation of the AAP’s recommendation published in 2000 for routine US based on records from infants born between 2008-2011. William Hennrikus, M.D., medical director, Penn State Pediatric Bone and Joint Institute Clinic, notes, “The findings from Pacana’s work suggest that utilizing US for all breech births is costly and yields a very low number of cases that require intervention for hip dysplasia. It is an important observation that may impact how breech birth infants are followed early for possible hip dysplasia.”
Dr. Hennrikus served as a mentor to Michael J. Sumko, D.O., an orthopedics resident at PinnacleHealth who completed orthopaedics training at Milton S. Hershey Medical Center. Dr. Sumko won the 2012 AAP Young Investigators Award for his study findings that describe radiation exposure with use of a mini C-arm for reduction of pediatric upper extremity fractures, also recently published in the Journal of Pediatric Orthopaedics.² Unlike prior studies which estimated radiation exposure with the C-arm, Dr. Sumko and colleagues measured actual exposure with use of the C-arm in the emergency department over the course of one year. In most cases, exposures exceeded those from conventional X-rays and were greater than previously estimated. To reduce radiation exposure, Sumko, et al., recommended that residents receive more training for safer use of the mini C-arm in the emergency department. The Department of Orthopaedics at Penn State College of Medicine now offers annual training for all residents and faculty in safe use of the mini C-arm.
Dr. Hennrikus notes, “Conducting studies of this size and complexity, presenting at a national meeting and publishing the findings in a top tier journal really becomes a team effort spanning several years. These research efforts help to fulfill our core missions: excellence in patient care, research, education and community service.”
William Hennrikus, M.D.
Professor, Orthopaedics and Rehabilitation
Medical Director, Pediatric Bone and Joint Institute Clinic
Surgeon, Pediatric Orthopaedics
FELLOWSHIP: Pediatric orthopaedics, Harvard Medical School, Boston, Mass.
RESIDENCY: Orthopaedic surgery, Balboa Naval Hospital, San Diego, Calif.
MEDICAL SCHOOL: Georgetown University School of Medicine, Washington, DC
- Pacana MJ(1), Hennrikus WL, Slough J, Curtin W. 2015. Ultrasound Examination for Infants Born Breech by Elective Cesarean Section With a Normal Hip Exam for Instability. J Pediatr Orthop. Oct 21. [Epub ahead of print]
- Sumko MJ, Hennrikus W, Slough J, Jensen K, Armstrong D, King S, Urish K. 2015. Measurement of Radiation Exposure When Using the Mini C-Arm to Reduce Pediatric Upper Extremity Fractures. J Pediatr Orthop. Feb 26. [Epub ahead of print]
Preventing Arthritis in Younger Patients Using Atraumatic Surgical Hip Dislocation and Periacetabular Osteotomy
Young active patients (15 to 40 years of age) who complain of non-specific worsening hip pain can present a challenge for clinical assessment: routine imaging and examination may be inconclusive with no evidence of instability or arthritis. According to Henry Boateng, M.D., orthopaedic trauma surgeon, Bone and Joint Institute, “This presentation can be a result of femoroacetabular impingement, hip dysplasia or a combination of the two. If treated early, before significant damage to articular cartilage occurs, it’s possible to relieve pain and prevent articular damage.” Dr. Boateng further describes, “Ganz periacetabular osteotomy (PAO) is an effective treatment for hip dysplasia in young adults; impingement symptoms are typically treated by decompression either with hip arthroscopy or open surgical dislocation. Though the two are very similar, it is important to distinguish between them and apply the correct treatment.” Continue reading
With increasing costs for spine treatments and more push-back from insurance companies questioning effectiveness, safety and value, cost containment strategies have become a major factor influencing spine treatment choices for patients.¹ Currently, a large part of the value equation includes process of care measures and direct costs associated with devices, surgery and length-of-stay. Jesse Bible, M.D., assistant professor and orthopaedic spine surgeon, Bone and Joint Institute, predicts a potential shift toward a broader, patient outcomes-driven value equation within the next five years. Continue reading
Acute treatment decision-making for patients with multiple traumatic injuries including a mangled extremity is guided by the adage, “life before limb.” Non-life-threatening injuries limited to a single extremity, like the hand, pose a difficult dilemma; choosing preservation over amputation is not always the best approach for every patient. “Injuries limited to the hand are usually a result of operating machinery at work, around the home or farm, or firework-related accidents,” says Kenneth Taylor, M.D., Bone and Joint Institute, hand reconstruction specialist.
Dr. Taylor frequently attempts to stabilize the injury before deciding to preserve or amputate. “Patients are often in shock and a great deal of pain,” he explains. “Their decision may evolve over time, during or after acute care. Patients also need time to trust me personally, to listen to the information I’m sharing with them about what lies ahead during recovery.” Dr. Taylor firmly stresses, “The decision is highly personal and individual. What is possible surgically to preserve the hand is not always what is personally right for the patient.” Continue reading