NOVEMBER 2008 VOLUME XXXVII NUMBER 11 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

186	Guest Editorial: Two Case Reports of Benign and Tumor-like Lesions of Bone Kenneth A. Jaffe, MD Dr. Jaffe is Orthopaedic Surgeon, Alabama Spine and Joint Center, Birmingham, Alabama. Abstract not available. Am J Orthop. 2008;37(11):E186.
187	Subungual Extraosseous Chondroma in a Finger S. Alexander Rottgers, MD, Gutti Rao, MD, and Ronit Wollstein, MD Dr. Rottgers is a Resident, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Abstract not available. Introduction provided instead. Chondromas are benign cartilage-producing tumors that are commonly found in tubular bones but seldom form in extraosseous soft tissues. These tumors must be distinguished from their malignant counterparts by histology and biological behavior. The 3 types of extraosseous chondromas are intra-articular/para- articular chondromas, juxtacortical chondromas, and chondromas of soft parts. Intra-articular/para-articular chondromas are histologically different in that they include benign-appearing nuclei.1 Juxtacortical chondromas and chondromas of soft parts tend to have mild nuclear atypia, despite a benign clinical course, and differ only in their association with periosteum and synovium, respectively.2-9 Juxtacortical chondromas are adjacent to bone and subperiosteum, whereas chondromas of soft parts are found in various tissue planes often associated with synovium. Here we report the case of a rare subungual extraosseous chondroma that presented atypically and that was therefore treated aggressively with disarticulation, despite an ultimately benign pathologic evaluation. The subungual location caused the tumor to obliterate the overlying nail bed and nail plate, raising concern of a potentially malignant pathology during initial evaluation. In addition, the elderly male patient’s tumor was near the distal interphalangeal (DIP) joint. Disarticulation was planned before surgery not only because of potential malignancy but also because of location. Resection followed by reconstruction of the nondominant, index finger distal phalanx would have required a more complex procedure, such as a skin graft or a crossfinger flap, without a significantly improved functional outcome. These options necessitate more surgery with the morbidity of a donor site and a return to the operating room for pedicle division in the finger-flap option. These options went against the patient’s wish for minimal surgery. In this patient, the paucity of subungual soft tissue caused the tumor to appear in a juxtacortical location, though it actually sat in a supraperiosteal tissue plane. As a result, the tumor was found in close opposition to the underlying bone but lacked the classic radiologic findings of juxtacortical chondromas, such as bony saucerization and sclerosis.8,9 Having a better understanding of the nature of juxtacortical chondromas and chondromas of soft parts should aid surgeons in anticipating the diagnosis in the instance of atypical presentation and should help make them more comfortable managing treatment decisions surrounding these histologically worrisome, yet benign lesions. Am J Orthop. 2008;37(11):E187-E190.
191	Tumoral Calcinosis Presenting as Neck Pain and Mass Lesion of the Cervical Spine Benjamin E. Tuy, MD, Thomas K. John, MD, Anthony D. Uglialoro, MD, Kathleen S. Beebe, MD, Michael J. Vives, MD, and Francis R. Patterson, MD Dr. Tuy is Orthopaedic Surgery Resident, Department of Orthopaedics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey. Abstract not available. Introduction provided instead. In this article, we present the case of a woman in her early 50s who presented with neck pain. Imaging studies showed an expansile, lobulated, calcified mass in the posterior elements of C2-C3. An open biopsy was performed, and the removed tissue demonstrated tumoral calcinosis. We discuss tumoral calcinosis, including its etiology, radiographic features, and differential diagnoses. Am J Orthop. 2008;37(11):E191-E195.

554	Editorial—A Conversation With AAOS President E. Anthony Rankin, MD Peter D. McCann, MD Dr. McCann is Editor-in-Chief of this journal and Chair, Department of Orthopaedic Surgery at Beth Israel Medical Center, New York, New York. Abstract not available. Am J Orthop. 2008;37(11):554.
556	Cauda Equina Syndrome: A Comprehensive Review Alex Gitelman, MD, Shuriz Hishmeh, MD, Brian N. Morelli, MD, Samuel A. Joseph, Jr., MD, Andrew Casden, MD, Paul Kuflik, MD, Michael Neuwirth, MD, and Mark Stephen, MD Dr. Gitelman is Orthopaedic Resident, Department of Orthopaedic Surgery, Stony Brook University Medical Center, Stony Brook, New York. Cauda equina syndrome (CES) is a rare syndrome that has been described as a complex of symptoms and signs—low back pain, unilateral or bilateral sciatica, motor weakness of lower extremities, sensory disturbance in saddle area, and loss of visceral function—resulting from compression of the cauda equina. CES occurs in approximately 2% of cases of herniated lumbar discs and is one of the few spinal surgical emergencies. In this article, we review information that is critical in understanding, diagnosing, and treating CES. Am J Orthop. 2008;37(11):556-562.
564	Identification and Surgical Treatment of Primary Thoracic Spinal Stenosis John R. Dimar II, MD, Kelly R. Bratcher, RN, CCRP, Steven D. Glassman, MD, Jennifer M. Howard, MPH, and Leah Y. Carreon MD, MSc Dr. Dimar is Associate Professor, Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky, and Attending Surgeon, Leatherman Spine Center, Louisville, Kentucky. We report the surgical treatment results for 7 patients (4 men, 3 women; mean age, 49 years) who presented with myelopathy caused exclusively by primary thoracic spinal stenosis, predominantly in the lower thoracic spine. (Patients with concurrent ascending lumbosacral degenerative disease were excluded.) All patients received extensive nonoperative treatment before referral to our center. Surgical treatment consisted of wide posterior decompression and instrumented fusion (5 cases), anterior vertebrectomy and fusion (1), and anterior vertebrectomy with autograft strut followed by wide posterior decompression and instrumented fusion (1). Mean operative time was 313 minutes, mean blood loss was 944 mL, and there were no major postoperative complications. Minimum follow-up was 2 years. Five patients had significant improvement in myelopathy and were ambulating normally, 1 had modest improvement in ambulation, and 1 remained wheelchair-bound. All patients achieved solid radiographic fusions. After presenting these case studies, we review the current literature on treatment effectiveness. Primary thoracic spinal stenosis should be considered in patients who present with isolated lower extremity myelopathy, particularly when no significant pathologic findings are identified in the cervical or lumbosacral spine. Expedient wide decompression with concurrent instrumented fusion is recommended to prevent late development of spinal instability and recurrent spinal stenosis. Am J Orthop. 2008;37(11):564-568.
569	Eight-Centimeter Segmental Ulnar Defect Treated With Recombinant Human Bone Morphogenetic Protein-2 Niles D. Schwartz, MD, and B. Matthew Hicks, MD Dr. Schwartz is Attending Surgeon, Fort Wayne Orthopaedics, Fort Wayne, Indiana Abstract not available. Am J Orthop. 2008;37(11):569-571.
572	Recombinant Activated Factor VII as a Temporary Reversal Agent for Warfarin Anticoagulation: A Cautionary Report on an Off-Label Application David M. Kalainov, MD, and Leonard A. Valentino, MD Dr. Kalainov is Assistant Professor, Clinical Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Abstract not available. Am J Orthop. 2008;37(11):572-574.
575	Failure of the Vari-Angle Hip Screw System: Two Cases Philip Daniel Nowicki, MD, and Gregory Minas Georgiadis, MD Dr. Nowicki is Resident Physician, Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio. Abstract not available. Am J Orthop. 2008;37(11):575-576.
577	Hypoplasia of the Left Superior Ramus of the Pubis Marc Wahlquist, MD, Henry Iwinski, MD, and Patrick J. Serey, MD Dr. Wahlquist is Orthopedic Resident, Medical University of Ohio, Toledo, Ohio. Abstract not available. Am J Orthop. 2008;37(11):577-578.
579	Reconstruction of a Chronic Distal Biceps Tendon Rupture 4 Years After Initial Injury L. Pearce McCarty, III, MD, Joshua M. Alpert, MD, and Charles Bush-Joseph, MD Dr. McCarty is with Sports and Orthopaedic Specialists, Minneapolis, Minnesota. Rupture of the distal biceps insertion can produce, on average, a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow. In acute biceps tendon ruptures in which a patient will not tolerate resulting functional deficits, anatomical reinsertion of the biceps tendon into the radial tuberosity is usually recommended. The various surgical techniques that have been described for anatomical repair of distal biceps rupture include passage of the tendon stump through a transosseous tunnel and use of suture anchors, interference screws, and EndoButtons (Smith & Nephew, Andover, Mass). Reported results for these techniques have mostly been excellent with respect to restoration of functionality. Chronic cases, however, may involve retraction of the native tendon and extensive scar formation, which preclude anatomical repair. In these situations, one of several described reconstructive techniques, including use of semitendinosus autograft and Achilles tendon allograft, may be needed to reestablish acceptable function. Delayed (≤18 months) reconstruction of chronic ruptures, using allograft soft-tissue constructs, has been described in the literature. We present the case of a chronic distal biceps rupture reconstructed 4 years after initial injury using a single-incision technique with free semitendinosus autograft and EndoButton fixation. Am J Orthop. 2008;37(11):579-582.
583	Hamstring Injuries Paul D. Clifford, MD Dr. Clifford is Clinical Assistant Professor of Radiology, Chief of Musculoskeletal Imaging, Director of MSK Fellowship Program, and Director of MRI Fellowship Program, Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida. Abstract not available. Am J Orthop. 2008;37(11):583-585.
586	Percutaneous Achilles Tendon Repair Using Ring Forceps Paul C. Kupcha, MD, and W. G. Stuart Mackenzie, MA Dr. Kupcha is Orthopedic Surgeon, Delaware Orthopaedic Centre, Wilmington, Delaware. In this article, we describe a method of percutaneous repair of acute Achilles tendon ruptures. We suggest an inexpensive and practical technique, using standard ring forceps, that produces results comparable with those obtained with Dr. Richard Stern’s Achillon apparatus. Am J Orthop. 2008;37(11):586.

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