MAY 2010 VOLUME XXXIX NUMBER 5 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

39	Unusual Presentation of Cobalt Hypersensitivity in a Patient With a Metal-on- Metal Bearing in Total Hip Arthroplasty Venkatachalapathy Perumal, MD, Martha Alkire, CNP, and Michael L. Swank, MD Dr. Perumal is an orthopedic surgery fellow, Cincinnati Orthopaedic Research Institute, Cincinnati, Ohio Pain after hip arthroplasty is less likely to be attributed to dermal sensitivity from orthopedic implants. Unexplained persistent pain after hip arthroplasty typically leads to further investigation, occasionally revealing a metal sensitivity. Our case study presents an unusual finding of a delayed type IV cobalt hypersensitivity in a patient several years after use of cobalt in the contralateral hip. Recognition and a high index of suspicion are needed for timely treatment of metal allergy when it presents as persistent pain after hip arthroplasty. Am J Orthop. 2010;39(5):E39-E41.
42	A Rare Case of Segmental Neurofibromatosis Involving the Sciatic Nerve Aron Trocchia, MD, Alma Reyes, MD, Jon Wilson, MD, and Kimberly Les, MD Dr. Trocchia is an Orthopaedic Resident, Department of Orthopaedics, William Beaumont Hospital, Royal Oak, Michigan. Segmental neurofibromatosis (NF-5) is an extremely rare variant of neurofibromatosis involving a single extremity without pathologic features beyond the midline. A case of segmental neurofibromatosis involving the sciatic nerve and its branches is presented with a detailed description of the patient’s preoperative findings plus postoperative course through 1-year follow-up. Clinical, histologic, and genetic findings are given along with a brief review of the literature on segmental neurofibromatosis. Last, treatment options and postoperative care recommendations are provided. Am J Orthop. 2010;39(5):E42-E45.
46	Failed Metal-on-Metal Total Hip Arthroplasty Presenting as Painful Groin Mass With Associated Weight Loss and Night Sweats Håvard Molvik, MRCS, Sammy A. Hanna, MRCS, and Nicholas J. de Roeck, FRCS (Orth) Mr. Molvik is Core Trainee in Orthopaedics, Department of Orthopaedic Surgery, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom. We report an unusual case of a failed metal-on-metal total hip arthroplasty presenting as a groin mass with associated weight loss, night sweats, and raised inflammatory markers. After a malignant process was ruled out, the patient was found to have a loose acetabular component. Histopathologic results revealed features of an aseptic lymphocytic vasculitic associated lesion. All symptoms resolved completely after the metal-on-metal bearing was revised to metal-on- polyethylene. Am J Orthop. 2010;39(5):E46-E49.

222	When Caregivers Stop Caring Glenn B. Pfeffer, MD Dr. Pfeffer, the journal’s Associate Editor for Foot and Ankle, is Director, Foot and Ankle Center, Cedars-Sinai Medical Center, Los Angeles, California, and President of the California Orthopaedic Association. Abstract not available. Am J Orthop. 2010;39(5):222.
223	Bone Graft Placement by Modified Plastic Syringe Amar Patel, MD, Christopher Born, MD, and Eugene Koh, MD, PhD Dr. Patel is Fellow, Department of Orthopaedic Surgery, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island. Several fracture patterns with resulting bony defects require augmentation with bone graft or other orthobiologics. Accurate placement of graft may be difficult when the area to be augmented is not readily accessible. In such a case, a quickly modified 3-mL plastic syringe may be a useful and efficient delivery method for accurate placement and impacting of the graft. Am J Orthop. 2010;39(5):223-224.
227	Economic Burden of Plantar Fasciitis Treatment in the United States Kuo Bianchini Tong, MS, and John Furia, MD Mr. Tong is President and Founder, Quorum Consulting, San Francisco, California. Although plantar fasciitis (PF) is prevalent among adults in the United States, few studies have quantified the economic burden of this condition. In the present study, which was based on PF treatment patterns identified by Riddle and Schappert in 2004, we quantified the costs of treatment and explored the magnitude of the burden on third-party payers. Costs for these established treatment options were obtained from 2007 fee schedules and relative value units released by the Centers for Medicare and Medicaid Services. These rates were used to determine a range of costs for treating PF. We projected that in 2007 the cost of treatment to third-party payers ranged from $192 to $376 million. Future studies may provide additional insight into treatment details and cost- effectiveness. Am J Orthop. 2010;39(5):227-231.
238	Structural Bone Allograft in Pediatric Foot Surgery Philip D. Nowicki, MD, Chester M. Tylkowski, MD, Henry J. Iwinski, MD, Vishwas Talwalkar, MD, Janet L. Walker, MD, and Todd A. Milbrandt, MD, MS Dr. Nowicki is Fellow, Pediatric Orthopaedics, Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan. Structural bone allografts are used in a variety of surgical procedures, but only a few investigators have examined their use and associated complications in the pediatric population specifically. In a retrospective review of pediatric foot procedures, we sought to determine types and rates of complications associated with structural bone allografts as well as time to incorporation of these allografts. Minimum follow-up was 12 months. Eighteen patients with 31 structural allografts were reviewed. The total complication rate was 7.1%, and the allograft incorporation rate was 90% (mean time after surgery, 9 months). Mean follow-up was 22 months. There were no pseudarthroses, nonunions, or fractures at the bone-graft sites. Structural bone allografts can be safely used in foot procedures in pediatric neuromuscular patients without major risk for complications, and their use can reduce autograft-harvest morbidity in pediatric patients with neuromuscular conditions. Am J Orthop. 2010;39(5):238-240.
242	Ankle Fracture Syndesmosis Fixation and Management: The Current Practice of Orthopedic Surgeons Eric Bava, MD, Timothy Charlton, MD, and David Thordarson, MD Dr. Bava is Resident, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. There is a wide variety of treatments for disruption of the syndesmosis. There is also controversy as to which device should be used for fixation of the syndesmosis, how many devices should be used, how many cortices the screws should engage, and whether, when, and where the screws should be removed. We conducted a study to determine how orthopedic surgeons manage these injuries. In a survey, we asked orthopedic trauma and foot and ankle fellowship directors and members of the Orthopaedic Trauma Association and the American Orthopaedic Foot and Ankle Society how they routinely treated the syndesmotic injury component of Danis-Weber type C or Lauge-Hansen pronation-external rotation type IV ankle fractures. The overall response rate was 50% (77/153). Fifty-one percent of respondents routinely used 3.5-mm cortical screws, 24% routinely used 4.5-mm cortical screws, and 14% routinely used a suture fixation device. Forty-four percent of respondents routinely used 1 screw, 44% routinely used 2 screws, and the rest were undecided between 1 and 2 screws. Twenty-nine percent of respondents engaged 3 cortices with syndesmotic screws, and 67% engaged 4 cortices. Syndesmotic screws were routinely removed 65% of the time and left in place 35% of the time. Routine removal of syndesmotic screws was done in the operating room in 95% of cases; it was done at 3 months in 49% of cases, at 4 months in 37%, and at 6 months in 12%. The most common method for treating syndesmotic injuries was through use of 3.5-mm screws engaging 4 cortices routinely removed in the operating room at 3 months. Number of screws used to fix the syndesmosis, either 1 or 2, was evenly split. Am J Orthop. 2010;39(5):242-246.
247	Assessment of Injuries Sustained in Mixed Martial Arts Competition James F. Scoggin III, MD, Georgiy Brusovanik, MD, Michael Pi, MD, Byron Izuka, MD, Pierre Pang, MD, Seren Tokumura, BS, and Gaetano Scuderi, MD Dr. Scoggin is Assistant Clinical Professor, John A. Burns School of Medicine, Honolulu, Hawaii, and is an orthopedic surgeon in private practice at Honolulu Sports Medical Clinic, Inc., Honolulu, Hawaii. Mixed martial arts (MMA) competitions have gained much popularity, and the sport is watched by many millions annually. Despite ongoing controversy, there have been no objective studies of the injuries sustained in MMA based on on-site evaluation. In the study reported in this article, we attempted to delineate injury patterns for MMA participants. We conducted an observational cohort study of MMA competitions held in Hawaii between 1999 and 2006. The study included 116 bouts, involving 232 “exposures” and 179 male participants between ages 18 and 40. All the fighters were examined by 1 of 4 physicians, both before and after each bout. Fighters were referred to an emergency department when necessary, and follow-up was recommended as needed. Among the 232 exposures were 55 injuries: 28 abrasions and lacerations (6 requiring on-site suturing or referral to an emergency department for suturing), 11 concussions (4 with retrograde amnesia), 5 facial injuries (2 nasal fractures, 1 tympanum rupture, 1 temporomandibular joint sprain, 1 Le Fort fracture), and 11 orthopedic injuries (3 metacarpal injuries, with 1 confirmed fracture; 1 acromioclavicular separation; 1 traumatic olecranon bursitis; 1 elbow subluxation; 1 midfoot sprain; 1 aggravation of elbow medial collateral ligament sprain; 1 elbow lateral collateral ligament strain; 1 trapezius strain; 1 Achilles tendon contusion). We describe the injuries sustained in MMA competition to make comparisons with other sports. We discuss distribution and mechanism of injuries as well as injury incidence based on on-site evaluation in MMA. Am J Orthop. 2010;39(5):247-251.
252	Morel-Lavallée Lesion Falgun H. Chokshi, MD, Jean Jose, DO, and Paul D. Clifford, MD Dr. Chokshi is Radiology Resident, PGY5, Department of Radiology, the University of Miami Miller School of Medicine, Miami, Florida. Abstract not available. Am J Orthop. 2010;39(5):252-253.

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