Measurement of Tibial Tubercle to Trochlear Groove (TT-TG) Distance by MRI for Patellofemoral Instability

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.

MRI Analysis

Analysis of MRIs reveals increased TT-TG distance of 21.36 mm in a patient with repeated patellar dislocation (left), compared to TT-TG distance of 10.49 mm in a patient without patellar dislocation (right).

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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

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Correction of Complex Hindfoot Deformities Using an Intra-medullary Nail

Correction of Complex Hindfoot Deformities Using an Intra-medullary Nail

Figure 1: A 57-year-old male presented with a history of ankle pain and deformity secondary to Charcot-Marie-Tooth disease. He reported a level 9 pain with weight bearing, utilized a cane and required custom footwear. Note on the X-ray the severe varus deformity on the AP and the degree of arthritis on the lateral X-ray.

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

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Orthopaedics Trainees Win Young Investigator Awards, Publish Findings

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.” Continue reading

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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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