Penn Orthopaedics

Penn Orthopaedics

Thursday, July 30, 2015

GPS for Better Knee Replacements

Penn Orthopaedics
David G. Nazarian, MD

While knee replacements are made better than ever, 20 percent of patients aren’t happy with their results. According to David G. Nazarian, MD, an orthopaedic surgeon, this is due to the fact that ligaments which stabilize the knees aren't always balanced.

"Oftentimes, surgeons jiggle the knee during surgery to get a sense of whether or not an implant was properly balanced," explains Dr. Nazarian.

This is now remedied by a new device embedded with pressure sensors.

Read the full story.

Wednesday, July 29, 2015

World's First Pediatric Double-Hand Transplant Performed in Philadelphia

L. Scott Levin, MD, FACS
Thanks to Penn Medicine surgeons from the departments of Orthopaedics, Transplant, and Plastic Surgery, Zion Harvey, 8, is the first child to receive a bilateral hand transplant. The procedure, which lasted 10 hours, took nearly two years to plan.

"The planning took approximately 18 months," said team leader L. Scott Levin, MD, FACS, chair of the Department of Orthopaedic Surgery at Penn Medicine and the director of Penn and CHOP’s Hand Transplant Program. "For those of you who are familiar with the book about Apollo 13, Failure Is Not an Option, that's how our team approached this transplant."

Zion suffered a life-threatening infection at age two that forced doctors to amputate both his hands and feet. Harvey says the new hands are a dream come true. "I just want to say this, never give up on your dreams. It will come true."

More Links:

8-year-old becomes 1st child to get double hand transplant
For the first time ever, doctors have transplanted donor hands and forearms onto a child. Eight-year-old Zion Harvey lost his hands and feet at the age of 2 due to a serious infection that also led to a kidney transplant.

8-Year-Old Boy Gets Double Hand Transplant in Surgical First
In a surgical first, Philadelphia doctors have transplanted donor hands and forearms onto an 8-year-old boy whose own hands were amputated when he was a toddler.

First Pediatric Bilateral Hand Transplant Performed
Led by Dr. Levin, a team of forty surgeons, anesthesiologists, nurses, and other clinicians at Children's Hospital of Philadelphia (CHOP) operated for 10 hours on an 8-year-old-boy earlier this month to achieve the world's first pediatric bilateral hand transplant.

Wednesday, July 8, 2015

Can Hip Preservation Help With Chronic Hip Pain?

Hip pain for young adults is different than it is for older adults.

In patients over age 65, the cause is usually pretty clear—arthritis or a fracture from a fall. In these cases, hip replacement is often a viable treatment.

Atul Kamath, MD
But hip pain for young adults is not always so black and white.

One of the most frustrating aspects of hip pain for young adults is not knowing the actual cause.

That’s in addition to living with daily discomfort, having to limit physical activities, or—worst-case scenario—being forced to abandon certain activities altogether.

The Penn Medicine Center for Hip Preservation, led by Atul Kamath, MD, an orthopaedic surgeon and Director of the Penn Medicine Center for Hip Preservation, aims to pinpoint the underlying cause of hip pain and repair the hip, rather than replace it.

Hip preservation techniques are often the best bet for treating young, otherwise healthy adults, who cannot or prefer not to have hip replacement surgery.

A Snapshot of Hip and Hip Pain

Hands on Your Hips
Wrap your hand around where your pants pocket is. This makes a “C” as you cup your hands along your side. If you can imagine your fingers touching your thumb deep within your groin, you’ve identified where the hip ball and socket really are. Because the hip is a deeply located joint, hip pain is often confused with a hernia, groin pain, or pelvic pain.

Whenever you use your legs, you’re moving the hip—walking, kicking, climbing stairs, squatting. When you bend down or stand up, you’re using your hips. That’s why even basic activities can eventually become debilitating for people with chronic hip pain.

Inside the Hip
Make a fist. Now, wrap the other hand around it. That’s similar to how the top of the thighbone (the femoral head) fits into the pelvis bone to form the “ball-and-socket” joint of the hip.

Cartilage, which acts like slippery rubber, covers the ends of those bones and helps them to glide over each other when you move. Cartilage helps your hips absorb the shock. When cartilage fails and is worn away, this results in “bone-on-bone” rubbing that causes the pain of arthritis.

Surrounding the hip joint are ligaments and joint capsule, which connect the femur to the pelvis bone. This whole structure is covered in multiple layers of muscles that extend down the front and back of your thighs to generate movement in your hips and legs.

Nerves start at the bottom of your spine, run through the hip area, and down your thighs. Your brain communicates through these nerves to tell your hips and thighs to move.

Because the nerves that wind their way through the hip start at the base of the spine, hip pain is commonly mistaken for lower back pain.

A Snapshot of Hip Preservation Patients

Dr. Kamath says patients who tend to be good candidates for hip preservation often fit into one of three groups:

1. Adolescents and Young Adults with developmental and post-traumatic disorders of hip
These patients have hip dysplasia (DDH, CDH), hip instability, effects or issues resulting from slipped capital femoral epiphysis (SCFE), and legg-calves-perthes (LCP) disease, among other commonly diagnosed conditions. They may have also had prior hip surgery as a child, or suffered a traumatic injury to the hip resulting in deformity. Oftentimes, these patients present in their teens and early 20’s with progressive hip pain.

2. Young Adults
These young patients are typically competitive athletes or performers. They tend to be in their teens and 20’s and 30’s and have generally more normal hip structure and healthy cartilage. Because they constantly put their hips into abnormal positions, they tend to be more susceptible to injuries. They may be diagnoses with femoroacetabular impingement (FAI), labral tears of the hip, tendon tears, cartilage damage, and other sports-related injuries.

“Athletes and dancers tend to put their hips in high or abnormal degrees of range of motion. They are used to pushing themselves,” says Dr. Kamath. “But hip pain can take even world-class athletes beyond their threshold of pain – and their performance suffers.”

The Center for Hip Preservation aims to help these athletes, performers, and dancers continue their activities by addressing the root cause of their hip pain.

3. Middle-Age Active Adults
These adults are generally 30 to 50 years old and are quite active. Because of the high demands they put on their bodies, they may cause damage within the hip joint, and, in some cases, may have early cartilage and soft tissue degeneration in the hip.

These adults are not candidates for hip replacement because they still have healthy articular cartilage. Depending on activity levels, careful evaluation of patient expectations, and ability to meet the demands of rehabilitation, these patients may be suitable candidates for certain hip preservation procedures.

Four Movements That Can Lead to Hip Pain

Cutting to rapidly
change direction
Kicking the leg
Internal Rotations
Turning one knee
toward the other
Raising the leg

A Snapshot of Hip Preservation Techniques for Young Patients

Hip preservation means restoring the structural health and function of the hip. It also means getting rid of the pain.

Treatments can include a variety of surgical and/or non-surgical methods for people who still have healthy cartilage but have underlying structural causes for their hip pain. The goal is to correct issues with joint anatomy, bones, and/or soft tissue in the hip to prevent further damage.

Meeting that goal starts with a detailed history of the hip pain in the patient’s own words. A key aspect of this evaluation includes imaging tests, such as X-rays, MRIs, and 3D CT scans. These tests show the anatomy and structure of the hip, the quality of the cartilage, and the gait mechanics during movement.

After a thorough medical examination, treatment options depend on the underlying cause of the pain. These options can include:
  • Arthroscopy: A minimally invasive hip surgery to address damage deep inside the hip joint, such as cartilage injury and areas of impingement
  • Surgical hip dislocation: An open surgery in which the hip is dislocated from the socket without reducing the blood supply, to address severe deformities and cartilage damage
  • Periacetabular Osteotomy (PAO or Ganz osteotomy): An open surgery to stabilize and realign the hip socket, particularly for dysplasia patients
  • Core decompression: A minimally invasive technique for avascular necrosis to decompress dead bone tissue in the hip socket. In the same procedure, stem cells from the pelvic bone can be re-injected to stimulate the growth of new, healthy bone tissue.
“No two hips are exactly the same, and no two problems are the same,” says Dr. Kamath. “You have to tailor the care to the individual patient. It’s a very patient-centered, individual approach.”

Tuesday, July 7, 2015

Chronic Hip Pain: Three Myths Young Athletes Tell Themselves

For many, chronic hip pain can start as a vague discomfort, more annoying than it is painful. Because of that, it is oftentimes simply ignored.

As time goes on, the pain may escalate from annoying to quite disabling. Many patients will try to ease the pain with medication, rest, massage, or quitting their favorite activities altogether.

Dr. Kamath
Atul Kamath, MD
In some cases, particularly for younger patients, they've gone to see a physician and haven’t seen an improvement, received an accurate diagnosis, or found the right treatment.

"In the '90s and early 2000s, young patients with hip pain were often told, 'Nothing's really showing up on the X-ray. Do physical therapy, deal with the pain, and if you have more advanced changes in the hip in the future you may be a candidate for hip replacement,'" says Atul Kamath, MD, an orthopaedic surgeon and Director of the Penn Medicine Center for Hip Preservation.

The first step to identifying the cause and proper treatment for chronic hip pain may come before you’ve even entered the doctor's office. It’s having an honest conversation with yourself, especially if you believe the following myths:

"I’m too young to have hip pain."

When most think of hip pain, they think of an adult over the age of 65 with arthritis or a hip fracture from a fall.

Although Dr. Kamath does work with this population, his specialty is younger patients.

This includes young adults, whose hip pain often comes from a traumatic injury like a car accident or an overuse injury from a demanding physical activity.

"It’s a passion of mine to see young patients," says Dr. Kamath. "That's the biggest win—helping a young patient prevent future hip joint damage down the road. Intervening early can help stave off hip replacement in the properly indicated patient with true, correctable hip pathology."

Six Signs It's Time to See a Specialist About Hip Pain

  1. The pain has intensified over time.
  2. You’ve increasingly modified or limited activities, but still feel pain.
  3. You hear snapping, popping, clicking, or grinding with certain movements.
  4. Tendinitis and bursitis have been ruled out.
  5. You’re taking pain medications more frequently or in higher doses.
  6. You’ve developed a limp.

"It'll go away."

This is a myth that many middle-aged recreational athletes tell themselves when hip pain arises.

It may be true, or it may be a way to avoid getting treatment.

"You'd be amazed at the spectrum of how people modify activities to compensate for hip pain," says Dr. Kamath.

They find themselves cutting back on their activities or playing with less intensity. "They love to play singles tennis, then because of hip pain, they're barely able to keep up in doubles play," explains Dr. Kamath.

"Then they say, 'Well, maybe I'll just take a season off and switch to elliptical or swimming.' It's a slow, subtle decline for some," he adds.

Others try to self-medicate by focusing only on treating the symptoms of pain. They may try a host of oral pain medications, or seek alternative therapies like massage and acupuncture.

"Those are good methods to help recovery, but they may not help address the true underlying problem," Dr. Kamath says. "I would encourage those approaches, but only as a multi-modal strategy in conjunction with addressing the underlying structural issue."

"This will end my career."

This myth is a source of anxiety for high-performing athletes and competitive performers and dancers who fear that their hip pain signals a potentially career-threatening injury.

"They put their hips – whether structurally "normal" or abnormal – into high ranges of motion and seek medical attention because of an acute injury or chronic overuse," explains Dr. Kamath.

In their minds, addressing the hip pain may mean major surgery.

However, Dr. Kamath says hip preservation methods may be a better option. "Many have great cartilage and the health of the joint is good, but the pain comes from a clear structural issue," he explains.

Structural issues include labral tears, cartilage injury, tendon tears and bony impingement. "Femoroacetabular impingement" or FAI is a type of bony impingement in which a collision occurs between the femur bone and the hip socket rim with extremes in range of motion. This may result in damage within the hip joint itself.

Dr. Kamath reassures these patients that, even if surgery is recommended, the goal is to get them back to their activity after a full recovery and appropriate, targeted rehabilitation.

"Even if surgery is not an option," Dr. Kamath says, "get an understanding of the problem and nail down a diagnosis, so you can start to target the right solutions and move forward to positively affect your hip pain."

Monday, July 6, 2015

How to Avoid a Second Tommy John Surgery

In part one of this series, we looked at why Tommy John surgery can help a pitcher improve dramatically. In part two, we’ll look at how to avoid re-injury.

Penn Musculoskeletal Center
G. Russell Huffman, MD
Tommy John procedures repair a torn ulnar collateral ligament (UCL) in the elbow that usually stems from overuse, basically throwing too many pitches. The surgery is so effective that many athletes think it actually helps them perform better.

So, here’s the dilemma: If Tommy John surgery is so good, why do so many athletes end up re-injuring themselves and needing a second surgery?

G. Russell Huffman, MD, Director of the Shoulder and Elbow Fellowship Program at the Penn Musculoskeletal Center, explains how pitchers and other athletes can avoid a repeat injury and round two of Tommy John surgery.

The Problem

According to ESPN, nearly 35% of pitchers who had Tommy John surgery in 2014 had the procedure before. The reason so many pitchers need a second Tommy John surgery? The underlying issues or problems that caused the ligament to be torn weren’t corrected in the first place.

Dr. Huffman says that this can happen due to four key issues:
  1. Not stretching your shoulder regularly
  2. Weak core strength
  3. Poor body mechanics with hip and leg rotation
  4. Not resting properly 
He adds that if these are the fundamental problems and “just the ligament is reconstructed, it may be a temporary fix.”

Taking a Second Look

When Dr. Huffman sees patients, he performs in-office evaluations to assess potential issues and the likelihood of a second surgery, including:
  • Hip examinations
  • Core strength tests, such as single-leg squats
  • Shoulder strength and motion assessment
  • Elbow range of motion assessment
  • X-rays
  • MRIs
The key, however, to not having to endure revision surgery in the first place has to do with proper rehabilitation, which typically takes about 18 months.

Rehabilitation Following Tommy John Surgery

Although rehab is different for everyone, there are typically three phases patient needs to go through to get back to their previous level of ability.

Phase 1 (after surgery until six weeks): Immediately following surgery, the elbow is placed in a brace with no movement in a 90-degree position. The patient will typically need to wear this for close to two weeks. During this time, the patient may start to do gentle range-of-motion exercises for the wrist, hand and shoulder. This will help to maintain motion, strengthen those areas of the body and help to control pain.

Phase 2 (six weeks to four months): After about six weeks, most patients are able begin elbow-strengthening exercises and other mild-intensity workouts (such as cardiovascular, lower extremity and core stabilization exercises). At this stage, the main goal is to continue to protect the elbow and UCL. This is the time where movement/posture dysfunction and kinetic chain issues can be examined, so that they can be changed in an attempt to prevent future injuries.

Phase 3 (four months to six months): At this point, athletes may start to toss a ball without a wind-up motion. Once this is able to be done with no pain, they can begin to add an easy wind-up motion. It is recommended that the distance and number of throws is initially limited and gradually increased every couple weeks or after consultation with the rehab team.

The athlete should cut back the number of throws and distance if any pain is felt at this point. If the pain persists for a couple days, halt throwing and contact your physician.

Phase 4 (eight to 10 months): This is the final stage and where the athlete can return to pitching and throwing from a mound. It is still important to continue to build up strength and gradually increase the number of pitches thrown in a given session.

Pitching at 100% should not occur until about 11 or 12 months, depending on how rehab progressed.

Ultimately, avoiding repeat surgery comes down to knowledge. “Educating individuals in terms of knowing when their own body’s fatiguing and looking at warning signs are important,” adds Dr. Huffman.

Thursday, July 2, 2015

Why Pitchers Have Tommy John Surgery

When it comes to throwing a ball, most think the magic is in the arm or the shoulder. It’s not.

The secret sauce is body mechanics.

G. Russell Huffman, MD
“In reality, about seventy percent of the velocity of say, a fastball pitch, actually comes from the pitcher’s leg and torso,” explains G. Russell Huffman, MD, Director of the Shoulder and Elbow Fellowship Program at the Penn Musculoskeletal Center.

“The shoulder, elbow and hand are really for ball control more so than velocity,” he adds.

When a pitcher develops poor mechanics during prolonged use, Dr. Huffman says, “it can ultimately lead to shoulder or elbow injuries.”

The Surgical Solution

Elbow injuries are a common problem for pitchers, whether they play professionally or at an amateur level.

A common fix is Tommy John surgery.

The surgery, named after the Los Angeles Dodgers player who first had the procedure in 1974, fixes tears in the ulnar collateral ligament (UCL) of the elbow. This ligament connects the forearm bone (ulna) and the upper arm bone (humerus).

Where Pitching Problems Start

At the root of elbow injuries is poor mechanics. But that’s not the only problem.

Dr. Huffman cites overuse as another key factor. And when you’re good at what you do, the problem gets compounded.

ulnar collateral ligament (UCL) reconstructionAlso, younger athletes who participate in multiple leagues may end up pitching year-round. This prevents their bodies from fully resting and recovering.

Ensuring that the body recovers is critical, considering the severe nature of pitching.

“When you release the ball, it’s a pretty violent act,” explains Dr. Huffman. “Just the act of throwing and using all that stored energy in your body to transmit that into a moving object creates some damage that your body can handle.”

But if you don’t take time to rest during and after games, stretch, and let the muscles recuperate, “then the damage keeps building up,” he adds. “You start to lose motion through your shoulder, and then that translates down the arm into the elbow.”

Tommy John: The Repair Job

In Tommy John surgery, a tendon from another part of the body—usually the wrist—is used to reconstruct the damaged UCL in the elbow. The fairly quick procedure takes about 90 minutes.

Traditional Tommy John surgery requires the surgeon to drill a hole in the ulna and humerus bones, and thread the ligament through the bone.

The surgeons at Penn refined their surgical technique, which allows athletes to perform on a higher level.

“We’ve developed a very reliable technique for doing both Tommy John and first-time revision surgery. It’s a little bit of a smaller incision and preserves a little more bone than the traditional fix,” says Dr. Huffman.

Recovery, no matter which technique is used, usually takes up to 18 months.

Why Pitchers Feel They’re Better Than Before

Dr. Huffman says there’s a perception among players that the surgery makes pitchers better.

That’s because it does.

Players understand good mechanics. So, they shift their focus to prevent re-injury.

“The first step is building up leg and core strength,” says Dr. Huffman. Then, it’s about consistent shoulder stretching and helping athletes become better advocates for themselves by letting coaches know when they need rest.”

When pitchers prepare to go back for their first full season, Dr. Huffman applies the rehab approach for golfers: short, quality outings.

“They have high-quality outings with a lot of strikes, so no one gets discouraged, and they’re not overutilized,” Dr. Huffman says. “I think that’s a smarter way to go back, rather than trying for a complete game the first day out.” In part two of this series, we look at why repeat Tommy John surgeries are on the rise and how to prevent them.

Sunday, June 21, 2015

On the Move: The Health Benefits of Running

Whether it's a 5K, 10K, Color Run, Tough Mudder or Marathon, it seems as though everyone is out for a run. Once reserved only for die-hards, more and more people are running for the experience and the fun than ever before. Many also see it as a way to relieve stress after a busy day, an opportunity to get a group of friends together or to simply help out a good cause.

Regardless of the reasons or motivations, there are many health benefits for those that pick up the sport.

Kate E. Temme, MD,
"Running has numerous proven health benefits including cardiopulmonary fitness, weight management, stress relief and emotional well-being," says Kate E. Temme, MD, Assistant Professor of Clinical Physical Medicine and Rehabilitation.

There are, though, risks that go along with this sport. Runners are at a high risk for injury, especially those affecting the lower extremities. Knee injuries make up approximately 40% of running injuries, with runner's knee (patellofemoral pain syndrome) being the most common knee complaint.

With that being said, there are some tips that beginners (or those that have taken an extended break from the sport) should follow to ensure a safe and enjoyable experience.

If you are recovering from an injury or have an existing health condition, check with your doctor to make sure running is the right activity for you. If you've run in the past, but haven't been active in a while, build up your level slowly, before returning to your previous routine. Do a warm up for a few minutes each time and add a few minutes or some distance on to your run every few days.

Penn Medicine Sports Medicine
It is also important to focus on hip and core muscle development, as well as strength and flexibility of the muscles/structures directly surrounding the knee (quadriceps, hamstrings, iliotibial band). These muscles are important because they help to provide stability to the knee while you run. Since running occurs only in the frontal/forward plane, it is recommended that cross training include activities in the lateral/side plane to address hip strengthening for knee injury prevention.

Some believe that the more you run, the less susceptible you are to injury. This is not the case, though, as the repetitive nature of running increases the risk of overuse injuries. Lower extremity injuries are especially common in those who run more than 40 miles per week. Distance runners have the highest rates of stress fractures among athletes, with women being more susceptible than men. Training errors as well as nutritional deficits, among other things, increase the risk of injury to bone.

Given that stress fracture treatment may require a lengthy absence from running, prevention becomes an important goal. Shin splints (medial tibial stress syndrome) may lead to stress fractures and should be addressed with appropriate activity modification to prevent progression.

"Slowly increasing your mileage and intensity, avoiding abrupt changes in running surfaces, replacing shoes every six months or 300-400 miles, incorporating rest days into your training schedule and maximizing your calcium and vitamin D intake are all important for stress fracture prevention," said Dr. Temme. "Most importantly, ensuring that you are eating enough to fuel your body AND your sport is paramount for bone health. Seeking expert advice from a Sports Physician or Sports Dietitian can help ensure you are meeting your unique nutritional needs for safe training and competition."

Penn Orthopaedics
Regardless of the distance you decide to run, the number of times per week you do so, know that you are taking a step in the right direction for your health. Set small goals for yourself and fight that mental battle to achieve them. Join running groups, get your friends involved, whatever you need to do to stay inspired. As long as you are moving, you are achieving.

"Running is a convenient, economical and portable sport with many physical and emotional benefits," says Dr. Temme. "When introduced gradually, and with adequate attention to injury prevention, running can be enjoyed safely for years to come."