MARCH 2009 VOLUME XXXVIII NUMBER 3 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

49	Use of Flexible Intramedullary Nail Fixation in Treating Femur Fractures in Children Michael Khazzam, MD, Channing Tassone, MD, Xue C. Liu, PhD, MD, Roger Lyon, MD, Brian Freeto, MD, Jeffery Schwab, MD, and John Thometz, MD Dr. Khazzam is Orthopaedic Surgery Resident, Department of Orthopaedics, University of Missouri, Columbia, Missouri. We evaluated use of flexible intramedullary nails in the surgical treatment of femoral shaft fractures in 135 children (138 fractures). Mean age was 9.7 years (range, 2-17 years). Mean follow-up was 15.6 months (range, 6.6-53.5 months). Seventy-two patients were treated with stainless-steel (Ender) nails and 66 with titanium elastic nails. There were 73 midshaft fractures, 48 proximal-third fractures, and 17 distal-third fractures. Fracture patterns were transverse (66), oblique (42), spiral (24), and comminuted (6). There were 16 complications—3 refractures, 2 delayed unions, 3 varus or valgus malalignments, 5 nail-tip irritations, 2 broken interlocking screws (found incidentally on radiographs), and 1 asymptomatic proximal nail migration—for a complication rate of 11.7%. These results demonstrate that use of flexible intramedullary nails in the treatment of femoral shaft fractures in children is successful regardless of patient age, fracture location, or fracture pattern. Am J Orthop. 2009;38(3):E49-E55.
56	Isolated Lesser Trochanter Fracture Associated With Leukemia Jake P. Heiney, MD, MS, and Mark C. Leeson, MD, FACS Dr. Heiney is with the Department of Orthopaedics, ProMedica Health System, Toledo, Ohio. Abstract not available. Introduction provided instead. Isolated lesser trochanteric fractures are rare1; few cases have been reported in the literature. When an isolated lesser trochanteric fracture occurs in a patient with closed growth plates, it is thought to be pathognomonic for neoplasm.2-4 To our knowledge, this is the first report of a case of isolated lesser trochanteric fracture associated with leukemia. The other 18 reported cases of this fracture were associated with metastatic carcinoma (breast, pancreatic, thyroid, colon, prostate, lung, squamous cell), synovial cell sarcoma, non-Hodgkin lymphoma, or primary plasmacytoma.2-8 Am J Orthop. 2009;38(3):E56-E58.
59	Segmentally Fractured Femoral Küntscher Nail Extraction Using a Variety of Techniques Ayman M. A. Tadros, FRCSI, FRCS (Glasg.), and Piotr Blachut, FRCSC Dr. Tadros is Orthopedic Trauma Fellow, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada. Abstract not available. Introduction provided instead. Intramedullary nails are standard treatment for lower extremity long-bone fractures. Implant failure (nail fracture) is usually associated with nonunion but can occur with a healed fracture. Broken-nail extraction is usually required in the treatment of an associated nonunion but may also be indicated if symptomatic with a healed fracture. Extraction of a broken nail can be quite challenging. Many authors have described techniques for extracting the distal fragment of broken nails. In this article, we report the case of a patient with a segmentally broken Küntscher nail (K-nail) with a healed femoral shaft fracture. The nail was removed 14 years after fracture healing. Am J Orthop. 2009;38(3):E59-E60.
61	Repair of a Vascular Injury Associated With a Pediatric Femur Fracture Alfred Atanda, Jr., MD, Carl Magnus Wahlgren, MD, PhD, Giancarlo Piano, MD, and Christopher M. Sullivan, MD, MPH Dr. Atanda is Chief Resident, Division of Orthopaedic Surgery, University of Chicago Hospital, Chicago, Illinois. Abstract not available. Introduction provided instead. Pediatric vascular injuries are relatively uncommon. The risk for such injuries in the setting of blunt, orthopedic trauma is quite variable depending on the extremity involved. In regards to the thigh, there have been few reports of pediatric vascular disturbances resulting from femur fractures, blunt trauma, and benign neoplasms; however, none of these injuries required repair. To our knowledge, this is the first report of a child under age 15 who sustained an isolated femur fracture from blunt trauma that led to a vascular injury that required repair. Am J Orthop. 2009;38(3):E61-E63.
64	Surgical Anatomy of Latissimus Dorsi Muscle in Transfers About the Shoulder Benjamin A. Goldberg, MD, Bassem Elhassan, MD, Steven Marciniak, MD, and Jonathan H. Dunn, MD Dr. Goldberg is Attending Physician, Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois. Transfer of the latissimus dorsi to the greater tuberosity has been used successfully in the treatment of massive rotator-cuff deficiency. For safe release and transfer of the tendon, the variations in the tendinous insertions of the latissimus dorsi and teres major onto the humerus need to be understood. In anatomical dissection of 12 cadavers, mean width of the latissimus tendon was 3.3 cm at its insertion, and mean length was 7.3 cm. In all specimens, there were fascial connections between the latissimus and teres major and between the latissimus and the long head of the triceps. There were 3 insertion patterns of the latissimus dorsi tendon onto the humerus with respect to the tendon of the teres major: completely separate (8 cadavers), loosely bound (3 cadavers), and completely joined (1 cadaver). If the latissimus dorsi were being transferred in the last type, the teres major would need to be transferred with the latissimus dorsi as a common musculotendinous unit. Am J Orthop. 2009;38(3):E64-E67.
68	Use of Tibialis Anterior Tendon as Distal Landmark for Extramedullary Tibial Alignment in Total Knee Arthroplasty: An Anatomical Study Amar D. Rajadhyaksha, MD, Hemant Mehta, MD, and Steven B. Zelicof, MD, PhD Dr. Rajadhyaksha is Resident, Department of Orthopaedics, New York Medical College, Westchester Medical Center, Valhalla, New York. We studied the accuracy of using the tibialis anterior tendon (TAT) as a distal landmark for extramedullary alignment in total knee arthroplasty. Forty-five consecutive ankle magnetic resonance imaging scans were reviewed. On the computerized images, a digital ruler was used to measure the distance from the midpoint of the distal tibia (point M) to the TAT. Mean distance was 1.89 mm; range was 0 to 4.5 mm (95% confidence interval, 1.45-2.33). For 7 (15.6%) of the 45 scans, the distance was 0 mm. On 38 scans (84.4%), the TAT was within 2 mm of point M. The TAT is an easily palpable fixed anatomical structure that corresponds very closely to the midpoint of the distal tibia. Am J Orthop. 2009;38(3):E68-E70.

116	EDITORIAL—The Economy and Orthopedic Surgery 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. 2009;38(3):116.
117	Use of Single-Photon Emission Computed Tomography/Low-Resolution Computed Tomography Fusion Imaging in Detecting an Unusually Presenting Osteoid Osteoma of the Lumbar Vertebra Julie Hephzibah, MD, Bernice Theodore, MBBS, Regi Oommen, MD, DMRT, DRM, Kenny David, MS, Vinu Moses, MD, Sanjeev Shah, MD, and Jayalakshmi Panicker, DCP Dr. Hephzibah is Lecturer, Department of Nuclear Medicine, Christian Medical College, Vellore, India. In this article, we describe an unusual presentation of osteoid osteoma of the lumbar vertebra in a woman in her early 30s. Single-photon emission computed tomography/low-resolution computed tomography (SPECT/CT) fusion imaging was used to detect the osteoma, precisely localize the pathology site, and guide surgical excision of the lesion. In recent years, SPECT/CT fusion imaging has helped make interpretations of scintigraphic images significantly more accurate. Am J Orthop. 2009;38(3):117-119.
120	Proximal Tibial Stress Fractures Associated With Primary Degenerative Knee Osteoarthritis Ioannis Sourlas, MD, PhD, Georgios Papachristou, MD, PhD, Anastasia Pilichou, MD, Peter V. Giannoudis, MD, BSc, MB, Nicolas Efstathopoulos, MD, PhD, and Vassilios S. Nikolaou, MD, PhD Dr. Sourlas is Consultant, 2nd Department of Trauma and Orthopaedics, School of Medicine, Athens University, Athens, Greece. Tibial stress fractures are not rare—they have been extensively studied in young athletes and soldiers and in elderly people with rheumatoid arthritis, osteoporosis, Paget’s disease, pyrophosphate arthropathy, and hyperparathyroidism—but they seldom occur in patients with severe primary degenerative knee osteoarthritis. The etiology, diagnosis, and optimal treatment of these fractures remain a challenge. In this article, we review the English-language literature on the symptoms, diagnosis, treatment options, and final outcomes of these fractures, and we report 2 new cases of proximal tibial stress fractures in elderly women with severe primary degenerative knee osteoarthritis. Am J Orthop. 2009;38(3):120-124.
125	Total Hip Arthroplasty in Young Patients With Osteoarthritis Mariza Daras, MD, and William Macaulay, MD Dr. Daras is Resident, Department of Neurology, Duke University Medical Center, Durham, North Carolina. Total hip arthroplasty (THA), an effective treatment for patients with end-stage arthritic hip conditions, provides dramatic pain relief, enhances mobility, and restores function.The success of THA in older patients, in concert with improvements in techniques and biomaterials, has stimulated demand for this procedure in younger, more active patients hoping to regain full activity. Although young age remains a relative contraindication to THA, the weight of this factor has diminished. Several investigators have reported results of low-friction arthroplasty in young patients. Unfortunately, the value of these studies is limited because of heterogeneous hip pathology in the younger groups, particularly given that preoperative pathology has proved to significantly affect implant survival. In this review of the literature, we focus on THA survival in young, active patients with a preoperative diagnosis of noninflammatory osteoarthritis. Am J Orthop. 2009;38(3):125-129.
130	Cementless Total Hip Arthroplasties in Gaucher Disease: Long-Term Follow-Up Ehud Lebel, MD, Deborah Elstein, PhD, Ari Zimran, MD, and Menachem Itzchaki, MD Dr. Lebel is Senior Orthopedist, Department of Orthopaedic Surgery, Shaare Zedek Medical Center, Jerusalem, Israel. We retrospectively assessed the clinical and radiologic outcomes of 15 primary cementless total hip arthroplasties performed in 12 young adults with type I Gaucher disease. Mean Harris Hip Score was 86.9 points; patient satisfaction was high. There were no serious postoperative complications. Weight-bearing ambulation was immediate. Only 3 hips required revisions. In cases of Gaucher disease, cementless hip arthroplasties are safe and effective. Because patients with chronic metabolic disorders differ from healthy patients with traumatic fractures, the results reported in this article may have implications for nontraumatic hip arthroplasty. Am J Orthop. 2009;38(3):130-132.
133	Healing and Graft-Site Morbidity Rates for Midshaft Clavicle Nonunions Treated With Open Reduction and Internal Fixation Augmented With Iliac Crest Aspiration Robert Z. Tashjian, MD, and Daniel S. Horwitz, MD Dr. Tashjian is Assistant Professor, Department of Orthopaedics, University of Utah School of Medicine, University of Utah Orthopaedic Center, Salt Lake City, Utah. We conducted a study of the healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation (ORIF) augmented with iliac crest aspiration. Thirteen patients who had undergone ORIF augmented with iliac crest aspiration and tricalcium phosphate for symptomatic midshaft clavicle nonunions (5 hypertrophic, 8 atrophic) were retrospectively evaluated for nonunion healing, complications, and graft-site morbidity. No patient required intercalary allograft for severe bone loss. Ten nonunions had complete follow-up; 3 did not. Nine (90%) of the 10 with complete follow-up healed; the patient whose nonunion did not heal developed a postoperative infection. Five patients required hardware removal. No graft-site morbidity was documented. Clavicle nonunions treated with iliac crest aspirate augmentation have healing rates comparable to those of nonunions treated with autograft, as reported in the literature, and there is no graft-harvest-site morbidity. Am J Orthop. 2009;38(3):133-136.
138	Treatment of Acetabular Nonunion and Posttraumatic Arthritis With Bone Grafting and Total Hip Arthroplasty Paul S. Issack, MD, PhD, Mark P. Figgie, MD, and David L. Helfet, MD Dr. Issack is Fellow, Orthopaedic Trauma, Adult Reconstructive Surgery and Metabolic Bone Disease, Hospital for Special Surgery, New York, New York. Abstract not available. Am J Orthop. 2009;38(3):138-141.
142	Iatrogenic Femoral Nerve Palsy Masquerading as Knee Extensor Mechanism Rupture R. Justin Thoms, MD, Dimitry Kondrashov, MD, and Jeff Silber, MD, DCD Dr. Thoms is Orthopaedic Resident, Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York. Abstract not available. Am J Orthop. 2009;38(3):142-144.
145	Isolated Tears of Pectoralis Minor Muscle in Professional Football Players: A Case Series John E. Zvijac, MD, Bashir Zikria, MD, and Angie Botto-van Bemden, PhD Dr. Zvijac is Orthopaedic Surgeon, UHZ Sports Medicine Institute, Coral Gables, Florida. Our objective is to include pectoralis minor injuries in the comprehensive assessment of differential diagnoses for anterior chest wall pain or medial anterior shoulder pain sustained during blocking activities, which may present in football players. In this article, we report 2 cases of isolated pectoralis minor tears in professional football players and present mechanisms of injury, clinical presentations, appropriate diagnostic studies, and treatments. Am J Orthop. 2009;38(3):145-147.

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