Preventing Arthritis in Younger Patients Using Atraumatic Surgical Hip Dislocation and Periacetabular Osteotomy

Perioperative and Postoperative X-rays

Perioperative images (figures 1 and 2) of a 35-year-old patient diagnosed with marked symptom impingement. For these cases, Dr. Boateng used the lateral Gibson approach, which preserves the vascular supply to the joint. Figures 3 and 4 show the postoperative X-rays.

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

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How Do We Determine the Value of Spine Care?

Spine Treatment Models

Direct costs are directly attributed to patient care and commonly include physician visits, procedures, hospital stay, physical/occupational therapy, prescription medication, diagnostic testing/imaging, equipment and staff. Indirect costs are not directly related to patient care and mainly arise from loss of workforce productivity (missed time from work, decreased productivity when (and if) worker returns to work, and missed time from work by caregivers).

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

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Treating a Mangled Hand: Life Before Limb, but Then What?

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

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New Internal Technology in Limb Lengthening

The development of internally-placed, remote-controlled, magnetic intramedullary nails presents an exciting shift in treatment options for pediatric patients with a limb length discrepancies.1 This condition typically occurs from proximal focal femoral deficiency and fibular hemimelia.1 An internal lengthening device may be superior to the conventional external fixator lengthening, as it is less cumbersome, presents no major concern for pin site infections, is less painful and requires less patient input.

Limb Lengthening X-rays

Note the presence of adequate bony consolidation at the femoral lengthening osteotomy site. This femur was lengthened successfully with the internal magnetic ellipse nail without any malunion. Prior to the magnetic nail insertion, this patient had been treated for a valgus knee deformity with medial distal femoral hemiepiphyseodesis.

“Patients and their parents find this approach much more acceptable than a traditional external device, like the Taylor spatial frame. The patient can bend his or her knee and wear normal clothes; no one would know the child has the device. Clinically, because there are no pins, wires or screws attached to bone through the skin, there is a reduced risk of infection and less muscle and bone tethering,” explains Scott Sorenson, M.D., pediatric orthopaedic surgeon, Bone and Joint Institute. Continue reading

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Case Report: Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability

Patient History and Presentation:

A 25 year-old male presented with a complaint of significant recurrent shoulder instability and severe glenoid bone loss. Imaging revealed significant (50 percent) glenoid bone loss (Figures 1, 2). The patient reported multiple, recurrent dislocations related to recreational athletic activity. He was otherwise physically healthy.

Osteochondral Glenoid Reconstruction

Treatment Approach:

April Armstrong, M.D., Penn State Hershey Bone and Joint Institute, says: “Given the patient’s young age, baseline high level of physical activity and overall good health and significant glenoid bone loss, glenoid reconstruction using a fresh distal tibia allograft was chosen. With significant bone loss, such as in these cases, other traditional reconstructive options are not feasible, including traditional open instability or arthroscopic instability repair. The latarjet reconstruction is an option if there is less than 30 percent glenoid bone loss. However, these larger bone loss cases require either an iliac crest bone graft or this newer approach. The fresh distal tibial allograft is a good option in that it also has articular cartilage, but we don’t have long-term data to know if this is truly a clinical advantage. For a very young, athletic patient, this seemed the most desirable solution.”

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Developing an Adult Stem Cell Treatment Option for Posterior Tibial Tendon Dysfunction

Most patients with posterior tibial tendon dysfunction (PTTD, “fallen arches”) delay seeking treatment until the disease has progressed and requires surgery. Currently, available surgical approaches do not attempt to repair the degenerated posterior tibial tendon, but instead try to reinforce it with tendon transfers or decrease the load on the tendon via osteotomy or arthrodesis. Umur Aydogan, M.D., Penn State Hershey Bone and Joint Institute, and colleagues are currently investigating a novel autologous tibial tendon-derived adult stem cell approach for repairing and healing the damaged tendon, which is the underlying cause of the deformity.¹

Encouraging results from an initial preclinical investigation were described in a presentation at the 2015 American Foot and Ankle Society’s Summer Meeting in California; it was chosen as a finalist for the L. Goldner Award for best basic science article. Dr. Aydogan explains, “We isolated tendon-specific stem cells from the posterior tibial tendons of three patients with PTTD who were undergoing surgical repair. After six weeks in co-culture with tendon pieces, the stem cells began to differentiate into tenocytes. At 10 weeks, the tenocyte colony began to exhibit tendon structure.” (Figure) Adult stem cell characteristics and chondrogenic differentiation were confirmed using a combination of gene expression analysis and immunocytochemistry. This is the first time that human tendon stem cells have been isolated and successfully cultured to differentiate into tenocytes, with the potential to form healthy tendon tissue. Continue reading

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Medial Patella Femoral Ligament (MPFL) Reconstruction for Patellofemoral Instability

Medial Patellofemoral Ligament - Figure 1

FIGURE 1. The medial patellofemoral ligament (MPFL, yellow arrow) is a very thin ligament approximately 6 cm long.

Acute, trauma-related patella dislocation is a common knee injury seen in the orthopaedic clinic, most often in young athletes or highly active pediatric patients. Although conservative, nonsurgical management of an initial patella dislocation yields excellent results in most cases, up to 50 percent of patients may experience a recurrence, marked by underlying MPFL laxity that requires repair and reconstruction.1,2

Wayne Sebastianelli, M.D., Kalenak Professor of Orthopaedics and associate dean for clinical affairs at Penn State College of Medicine University Park Regional Campus notes, “With a recurrent or non-healing patellar dislocation, it’s important to identify the extent of the ligament and bone injury to devise an effective reconstruction approach. Commonly, in most cases, the MPFL has been ruptured or damaged.” Continue reading

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