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.
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.”
Successful 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.
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
LEFT: A well-placed and appropriately
sized headless compression screw in a
RIGHT: An oversized and slightly dorsal
placed screw has cut out of the dorsal
cortex of the distal phalanx in this female,
putting her at risk of fingernail injury and
Arthrodesis of distal interphalangeal (DIP) joints using headless compression screws for internal fixation is often used to relieve arthritis-related pain, instability, and deformity. New findings highlight important limitations in the broad use of this hardware in female patients and others with smaller bones. In women, 65 percent of small fingers and approximately 25 percent of women’s index and ring finger distal phalanges were too small to safely accommodate the 2.8 millimeter trailing thread diameter of commonly used commercially available cannulated compression screws.1 By contrast, less than 8 percent of male distal phalanges were too small for such screws. The findings are based on analysis of distal phalanges height and width from digital radiographs of 200 hands from 200 patients at Penn State Hershey Bone and Joint Institute.1
The lead investigator, Michael Darowish, M.D., explains, “Achieving DIP arthrodesis safely with headless compression screws in patients with smaller bones, particularly women, has been a concern, but the true extent of the issue wasn’t objectively investigated until now. That more than half of all female patients undergoing DIP arthrodesis may be affected is probably much greater than most surgeons would have guessed.”
Patellar tendon autograft ACL reconstruction [Click photo to enlarge for detail]
For young adult patients engaged in highly demanding competitive athletics or recreational sports, such as soccer, basketball, field hockey, and skiing, the cumulative risk of anterior cruciate ligament (ACL) injury, over time, is high. Young women are at particular risk, with two to eight times the incidence of ACL injury compared to men. Approximately 75,000 ACL reconstruction surgeries are performed annually in the United States. “The decision to do ACL reconstruction is partly based on the patient’s age, activity level, and post-reconstruction expectations. Some older patients may choose not to reconstruct the ACL at all if their activity levels are not demanding. These patients may instead opt to address the injury non-surgically,” explains Wayne J. Sebastianelli, M.D.
Patients who require ACL reconstruction and who want to return to pre-injury levels of aggressive activity need to receive a ligament graft; primary repair of the existing ligament is unlikely to yield a good result. Continue reading