JANUARY 2010 VOLUME XXXIX NUMBER 1 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

1	Septic Trochanteric Bursitis in an Adolescent Daoud Makki, MD, MRCS, DipSEM, and Alex James Watson, MBBS, FRCS (Orth) Dr. Makki is Trust Registrar, Department of Trauma and Orthopaedics, Princess Alexandra Hospital, Harlow, United Kingdom. Trochanteric bursitis, whether septic or inflammatory in origin, is a condition that affects middle-aged patients. Here we report the rare case of an adolescent with septic trochanteric bursitis (treated successfully with intravenous antibiotics), review the available literature on septic bursitis, illustrate the importance of prompt recognition and treatment of this condition in any age group, and describe the clinical presentation and the radiologic findings. Am J Orthop. 2010;39(1):E1-E3.
4	Fibula Stress Fracture Mimicking a Malignancy Charbel D. Moussallem, MD, Christine A. El-Yahchouchi, MS, and Ziad N. El- Khoury, MD Dr. Moussallem is Resident, Department of Orthopedic Surgery, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon. Stress fractures may be easily misdiagnosed as another entity, especially tumors, which may prompt very severe surgical treatment and sometimes amputation. The appropriate use of modern radiography may make the difference in proper diagnosis of stress fractures. Am J Orthop. 2010;39(1):E4-E6.
7	Pulmonary Embolism After Knee Arthroscopy Joel Tucker, MD, and Kevin Doulens, MD Dr. Tucker is Resident, Department of Orthopaedics and Rehabilitation, University of Florida, Jacksonville, Florida. Symptomatic deep venous thrombosis (DVT) after knee arthroscopy is a rare occurrence, especially in the ambulatory patient. In this report, we present an unusual case of pulmonary emboli in a young, active patient after arthroscopic treatment of an osteochondral defect via microfracture technique. We also review the current literature and recommendations for prophylaxis against postarthroscopic DVT. In our review, we found that DVT prophylaxis appears to effectively decrease nonsymptomatic DVT formation after knee arthroscopy. However, the relatively low rate of symptomatic DVT does not yet seem to warrant the associated risks of pharmaceutical prophylaxis. Further trials may provide more insight. Am J Orthop. 2010;39(1):E7-E10.

12	HITECH—The Carrot and the Stick: What Every Orthopedic Surgeon Needs to Know A. Herbert Alexander, MD Dr. Alexander is the journal’s Associate Editor-in-Chief; Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and CEO, Alexander Orthopaedics, P.A., Ketchum, Idaho. Abstract not available. Am J Orthop. 2010;39(1):12.
13	5 Points on Bearing Surfaces in Hip Arthroplasty S. Mehdi Jafari, MD, and Javad Parvizi, MD, FRCS Dr. Jafari is Research Fellow, Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Abstract not available. Am J Orthop. 2010;39(1):13-17.
18	A Simple Method for Fashioning an Antibiotic Cement–Coated Interlocking Intramedullary Nail Ryan U. Riel, MD, and Paul B. Gladden, MD Dr. Riel is Hand Fellow, University of Miami, Miami, Florida. Acute or chronic infection in the presence of nonunited fracture or chronic nonunion often necessitates staged surgical treatment. Treatment typically involves removal of hardware, debridement of infected tissue, use of local antibiotic delivery, and a long-term course of intravenous antibiotics. Several methods of local antibiotic delivery using antibiotic-impregnated polymethylmethacrylate (PMMA) have been commonly used, including commercial or hand-fashioned PMMA beads, antibiotic spacers, and antibiotic PMMA–coated guide rods. While these methods address the problem of infection, they do little to address fracture stability. In this report we describe a simple method for fashioning an antibiotic cement–coated interlocking intramedullary nail to treat an infected tibia fracture. This technique capitalizes on local delivery of antibiotics through use of antibiotic cement with the added benefit of improving fracture stability and fixation with an interlocking nail to achieve bony union. Am J Orthop. 2010;39(1):18-21.
22	Distal Humerus Osteotomy for Supracondylar Fracture Malunion in Children: A Study of Perioperative Complications Jennifer M. Weiss, MD, Robert M. Kay, MD, Peter Waters, MD, Scott Yang, BS, and David L. Skaggs, MD Dr. Weiss is Assistant Professor of Orthopedic Surgery, Children’s Orthopaedic Center, Childrens Hospital Los Angeles, Los Angeles, California, and Assistant Professor of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. Previous studies have found a wide range of perioperative complications associated with distal humerus osteotomies for malunion of supracondylar fractures in children. Our hypothesis was that the surgery would have few perioperative complications when performed at a pediatric center. We examined perioperative complications of corrective osteotomy for malunited supracondylar humerus fractures in 41 patients treated at Childrens Hospital Los Angeles between 1987 and 2002, and we established the risk factors associated with these complications. The overall complication rate was 32% (13/41). In the early surgeries, performed between 1987 and 1997, the complication rate was 53% (10/19); 6 (32%) of the 19 patients required reoperation. In the later surgeries performed during 1998 and 2002, the complication rate was 14% (3/22); no patient required reoperation. The complication rate was significantly lower (P = .0005) when lateral-entry pins were used to fix the osteotomy (13% [2/15]) than when other fixation methods were used (42% [11/26]). Using current techniques and performing the surgery in a pediatric center, we report a 0% reoperation rate and a 14% complication rate in distal humerus osteotomies for surgeries performed after 1997, a rate that we believe is acceptable. Furthermore, there are fewer complications of the surgery when lateral-entry pins are used to fix the osteotomy compared with other fixation methods. Am J Orthop. 2010;39(1):22-25.
26	Labral Support Shelf Arthroplasty for the Early Stages of Severe Legg-Calvé- Perthes Disease Chang-Wug Oh, MD, Andres Rodriguez, MD, James T. Guille, MD, and J. Richard Bowen, MD Dr. Oh was Research Fellow, Alfred I. duPont Hospital for Children (and from the Department of Orthopaedic Surgery, Kyungpook National University Hospital, Samdok, Chung-gu, Daegu, Korea). The best treatment for Legg-Calvé-Perthes disease remains unknown, and various methods of treatment have been shown to yield conflicting results. Treatment with a labral support shelf arthroplasty is ideal when an increased arc of the acetabulum is needed to contain an enlarged femoral head, when extension of the lateral border of the acetabulum is needed to prevent hinge subluxation, and when a larger surface area is needed for remodeling. Twenty patients with unilateral Catterall classes III and IV and lateral pillar groups B and C disease in the necrotic or fragmentation stage were treated with a shelf arthroplasty. Eleven hips demonstrated hinge subluxation. Success was defined as achievement of a round or oval femoral head, and failure was defined as a flat femoral head. Clinical examination evaluated the presence of pain, limp, and range of motion. Eighteen of the 20 hips (90%) had a successful result. Hinge subluxation was eliminated in all 11 hips. All 18 patients with a successful result had no pain, no limp, and a functional range of motion. The 2 hips considered a failure were in the oldest patients. Treatment with a labral support shelf arthroplasty fostered femoral head sphericity and prevented incongruence in hips otherwise at risk for poor results. Ninety percent of hips had a round or oval femoral head with no pain, no limp, and a functional range of motion. Am J Orthop. 2010;39(1):26-29.
30	Chondromyxoid Fibroma of the Radial Shaft Treated With Nonvascularized Fibular Autograft J. Bernard Bush, MD, John P. Sweeney, MD, Joseph E. Robison, MD, Brigitte DeMoss, MD, and Mark S. Meyer, MD Dr. Bush is with the Department of Orthopedics, Ochsner Clinic Foundation, New Orleans, Louisiana. Chondromyxoid fibroma is a benign yet highly recurrent neoplasm of bone, usually found in the metaphyseal segments of long bones. We present the case of an unusual diaphyseal chondromyxoid fibroma of the radius and review the literature regarding these rare chondroid neoplasms. Am J Orthop. 2010;39(1):30-34.
35	Painless, Atraumatic, Isolated Lateral Compartment Syndrome of the Leg: An Unusual Triad of Atypical Findings Luke S. Oh, MD, Paul B. Lewis, MD, Mark L. Prasarn, MD, Dean G. Lorich, MD, and David L. Helfet, MD Dr. Oh is Sports Medicine Fellow, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts. Compartment syndrome can be a devastating complication with significant morbidity when not recognized or treated expediently. Among the classic pentad of signs and symptoms associated with compartment syndrome, pain that is out of proportion to the injury is often cited as the earliest and most sensitive. We present a case report of an atypical presentation of compartment syndrome of the leg in which a patient taking lithium for bipolar disorder did not report pain out of proportion to the injury mechanism. Lithium has been implicated in altering pain perception and increasing the tolerance and threshold for pain, but this has not been widely reported in the orthopedic literature. In addition to compartment syndrome that was painless, the patient presented with 2 additional atypical findings. She presented with compartment syndrome that was atraumatic and isolated to only 1 out of the 4 compartments of the leg. A compartment syndrome that is painless, atraumatic, and isolated to a single compartment represents an unusual triad of atypical findings that has not been previously reported. With unusual presentations of compartment syndrome, there is an increased risk of late or unrecognized diagnosis, consequently increasing the likelihood of significant nerve damage or muscle necrosis. Clinicians have historically applied a higher level of scrutiny to patients who were deemed “obtunded,” that is, those in whom an assessment of pain cannot be reliably determined. In the past, obtunded patients have included intubated or comatose patients, infants and children, mentally disabled patients, and patients with altered mental status, nerve injury, or distracting injuries. Based on evidence from the psychiatry and anesthesia literatures, we propose that patients taking lithium should be added to this list of “obtunded” patients in whom a reliable assessment of pain may not be possible. Am J Orthop. 2010;39(1):35-39.
40	Arthroscopic Excision of a Painful Bipartite Patella Fragment Joseph Carney, MD, Darcy Thompson, MS, Joseph O’Daniel, MD, and Jeffrey Cassidy, MD Dr. Carney is Staff Orthopaedic Surgeon, Naval Medical Center San Diego, San Diego, California. Bipartite patella is an uncommon finding, with the majority of cases discovered incidentally on radiographs. Occasionally, bipartite patella can become painful through sports activities, overuse, or following an injury, and the large majority of these cases resolve with nonoperative treatment. However, for patients who do not respond to a prolonged course of nonoperative treatment, surgical options may be considered. We report a successful case of arthroscopic excision of a painful bipartite patella fragment in a 19-year-old male collegiate basketball player. A review of the literature is included. Am J Orthop. 2010;39(1):40-43.

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