MARCH 2007  Volume XXXVI No. 3 pISSN:1078-4519 eISSN:1934-3418

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31	Guest Editorial—Benign Nerve Tumor and Posttraumatic Nerve Palsy: A Common Thread? Matthew M. Tomaino, MD, MBA Hand, Shoulder, and Elbow Surgery, University of Rochester Medical Center, Rochester, New York 14642. Abstract not available. Am J Orthop. 2007;36(3):E31.
32	Benign Nerve Tumors of the Hand and the Forearm Chris J. Lincoski, MD, G. Dean Harter, MD, and David C. Bush, MD Chris J. Lincoski, MD, Geisinger Medical Center, Danville, PA 17822 (tel, 570-271-6541; fax, 570-271-5872). We used a hand surgeon’s 1978–1994 pathology reports to retrospectively review the incidence, preoperative and postoperative diagnoses, and presenting signs and symptoms of benign nerve tumors. Twenty-four (11.5%) of our series of 208 soft-tissue tumors of the hand and the forearm were benign nerve tumors. Nerve tumors were the third most common tumor after giant cell tumors of tendon sheath and inclusion cysts. Correct preoperative diagnosis was made in only 1 (4.2%) of the 24 cases. Schwannomas and neurofibromas were equally distributed (12 each), and 2 cases of neurofibromatosis (8.3%) were documented. Two (16.7%) of the 12 patients with schwannomas and 4 (33.3%) of the 12 patients with neurofibromas had neurologic symptoms. Six (85.7%) of the 7 digital tumors were dorsally located. In the literature, incidence of benign nerve tumors is much lower (ie, 1%-5%), and preoperative diagnosis consistently incorrect in our study. Incidence of neurologic symptoms (numbness, paresthesia) as presenting symptoms was higher in our study than previously documented. Although benign nerve tumors are most often located on the volar surface of the hand, 25% of the lesions we found were on the dorsal surface of the fingers. Am J Orthop. 2007;36(3):E32-E36.
37	Recurrent Schwannoma With Bony Erosion of the Distal Middle Finger: A Case Report Addison G. Wilson, Jr., MD, Eric P. Hofmeister, MD, and Michael Thompson, MD Addison G. Wilson, Jr., MD, Undersea Medical Officer School, Groton, Connecticut 06349-5159. Abstract not available. Introduction provided instead. Schwannomas, also known as neurilemomas, are a benign peripheral nerve sheath tumor composed of well-differentiated Schwann cells. Although they may be difficult to diagnose prior to surgery, schwannomas are distinguished intraoperatively as round, well-encapsulated eccentric tumors that are easily separated from local peripheral nerves.1-3 Although schwannomas are often associated with neurofibromatosis type 2, most occur sporadically.4-5 Treatment usually is simple mass excision while taking care to spare the contributory nerve.3-4 Recurrence after excision is rare,3,6,7 as is erosion of the adjacent bone.8-10 We present an unusual case of a schwannoma involving a digital nerve that not only had recurred multiple times but also had uncharacteristic bony erosion and nail bed destruction, which required bone grafting and nail bed reconstruction. Am J Orthop. 2007;36(3):E37-E39.
40	Peroneal Nerve Palsy Due to an Intraneural Ganglion: A Case Report of a 41/2-Year-Old Boy Hormozan Aprin, MD, Jacob Weinberg, MD, Elizabeth S. Lustrin, MD, and David Abrutyn, MD Hormozan Aprin, MD, North Shore Long Island Jewish Medical Center, Great Neck, New York 11021 (tel, 516-466-6181; fax, 516-482-9217). Abstract not available. Introduction provided instead. Intraneural ganglion cysts are rare, especially in the pediatric population. Most patients are male and present at a mean age of 34.1,2 These benign masses commonly occur in the peroneal nerve1-10 but have also been reported in the ulnar nerve,3,11-13 the posterior interosseous nerve,14 the median nerve,15 and the brachial plexus.16 Patients typically present with pain and motor deficit. Resolution of these symptoms has been documented with surgical removal of the cyst.1,4,5,9,13 We report a case of a peroneal nerve palsy caused by an intraneural ganglion in a 41/2-year-old boy. Am J Orthop. 2007;36(3):E40-E42.
43	Distal Femoral Physeal Fractures and Peroneal Nerve Palsy: Outcome and Review of the Literature John F. Sloboda, MD, Paul L. Benfanti, MD, John J. McGuigan, MD, and Edward D. Arrington, MD LTC Paul Benfanti, MCHJ-SOP, Madigan Army Medical Center, Tacoma, WA 98431 (tel, 253-968-3180; fax, 253-968-1586; e-mail, paul.benfanti@nw.amedd.army.mil). Abstract not available. Introduction provided instead. Distal femoral physeal injuries commonly result in growth disturbance. Leg length discrepancy or angular deformities occur in approximately 40% to 50% of patients.1 The mechanism of the physeal injury usually involves a varus or valgus force with resultant medial or lateral displacement of the epiphysis.2 Injury to popliteal neurovascular structures has been less commonly associated with distal femoral physeal fractures. The mechanism of neurovascular injury is a hyperextension force with anterior displacement of the epiphysis resulting in traction injury.1 Peroneal nerve injury in association with distal femoral physeal injury has been described in 6 patients.3-7 Four of 6 patients had complete return of peroneal nerve function by 6 months.4,6,7 Two patients had described peroneal nerve injuries, though outcome was not reported.3,5 We describe an additional patient who sustained a distal femoral physeal fracture with concomitant peroneal nerve palsy. Am J Orthop. 2007;36(3):E43-E45.

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119	Editorial The Annual AAOS Meeting: Memorable Peter D. McCann, MD Abstract not available. Am J Orthop.2007;36(3):119.
123	Modified Skew-Flap Below-Knee Amputation RAmitabh Jitendra Dwyer, MS Orth, Rajesh Paul, MS Orth, Maharaj Krishan Mam, MS Orth, D Orth, Jeewan Singh Prakash, MS Orth, and Richard Andre Gosselin, MD, MSc, MPH, FRCS(C), FAAOS Between 1999 and 2001, 35 consecutive patients with diabetes (mean age, 59.4 years) were treated prospectively with a modified skew-flap below-knee amputation. The technique, results, and follow-up are described. By a mean follow-up of 3.5 years, 3 patients required below-knee amputation of the opposite extremity, 4 expired, and 28 were ambulating with a below-knee prosthesis. The modification has several advantages: A tibialis anterior muscle cushion on the distal end of the tibia prevents bone protrusion; anterior skin flaps made by the initial linear anterior incision prevent tension at the suture line; and oblique myocutaneous flaps avoid muscle trimming and prevent shearing of fascial plexuses at closure, thus improving wound healing. Am J Orthop. 2007;36(3):123-126.
128	Evaluating Short-Term Pain After Steroid Injection Ronit Wollstein, MD, Gerson Chaimsky, MD, Lois Carlson, OTR/L, CHT, H. K Watson, MD, Gadi Wollstein, MD, and Jaber Saleh, MD Steroids are injected into joints for various indications. All steroid preparations relieve pain similarly over the long term. Therefore, decisions about which preparation to use are often arbitrary. We evaluated methylprednisolone acetate and a combination of betamethasone diproprionate and betamethasone sodium phosphate for short-term pain and the predictive value of short-term pain. Eighty-five patients were injected in prospective double-blind randomized fashion. Pain was evaluated by visual analog scale (1 = no pain, 10 = severe pain) at baseline, 3 days, and 3 weeks. No patient had joint pain immediately after injection. Three days after injection, mean (SD) pain levels were 5.1 (2.9) for methylprednisolone and 5.2 (2.6) for betamethasone (P = .97); 3 weeks after injection, they were 4.0 (2.8) and 3.7 (2.5), respectively (P = .57). Short-term pain increased from baseline for both preparations and decreased from 3 days to 3 weeks. Pain at 3 days and 3 weeks was positively correlated. This study does not support a difference in short-term pain between preparations. The significant correlation between short- and long-term pain may justify early decisions regarding treatment, especially in patients with high levels of initial pain. Am J Orthop.2007;36(3):128-131.
135	Thromboprophylaxis After Hip Fracture: Evaluation of 3 Pharmacologic Agents Gerard K. Jeong, MD, Konrad I. Gruson, MD, Kenneth A. Egol, MD, Gina B. Aharonoff, MPH, Adam H. Karp, MD, Joseph D. Zuckerman, MD, and Kenneth J. Koval, MD We compared the clinical efficacy and side-effect profiles of aspirin, dextran 40, and low-molecular-weight heparin (enoxaparin) in preventing thromboembolic phenomena after hip fracture surgery. All patients admitted with a diagnosis of hip fracture to our institution between July 1, 1987, and December 31, 1999, were evaluated. Study inclusion criteria were age 65 years or older, previously ambulatory, cognitively intact, home-dwelling, and having a nonpathologic intertrochanteric or femoral neck fracture. Each patient received mechanical thromboprophylaxis (above-knee elastic stockings) and 1 pharmacologic agent (aspirin, dextran 40, or enoxaparin); patients who received aspirin were also given a calf sequential compression device. Meeting the selection criteria and included in the study were 917 patients. Findings included low incidence of thromboembolic phenomena (deep vein thrombosis, 0.5%-1.7%; pulmonary embolism, 0%-2.0%; fatal pulmonary embolism, 0%-0.5%) and no difference among the 3 pharmacologic agents in thromboembolic prophylaxis efficacy. Use of enoxaparin was associated with a significant increase (3.8%) in wound hematoma compared with dextran 40 (1.6%) and aspirin (2.4%) (P<.01). The 3 agents were found not to differ with respect to mortality, thromboembolic phenomena, hemorrhagic complications, or wound complications. Am J Orthop. 2007;36(3):135-140.
143	Anatomic Variations in the Lateral Femoral Cutaneous Nerve With Respect to Pediatric Hip Surgery Marc A. Bjurlin, BA, Kelly E. Davis, BA, Edgar F. Allin, MD, and Denise T. Ibrahim, DO Variations were documented in the course of the lateral femoral cutaneous nerve (LFCN) in the upper thigh relative to anatomic landmarks in 22 adult cadavers using the Smith-Petersen incision for the anterior approach to the hip. Distances from the anterior superior iliac spine (ASIS) to the point of nerve entry into the thigh were normalized as percentages of the distance from the ASIS to the pubic tubercle (PT) to relate the data to small children. In all cases, the LFCN passed deep to the inguinal ligament, entering the thigh a mean of 2.6 cm (SD, 1.9 cm) medial from the ASIS (19%±14% of the ASIS-PT distance), with distances ranging from 0.3 to 6.5 cm (2.6%-46.4%). With the data extrapolated to children, the LFCN may commonly be found medial to the ASIS about one fifth the distance from the ASIS to the PT. In 32% of cases, the LFCN ran directly inferiorly, but in 68% it coursed inferolaterally and then turned to run inferiorly close to the distal part of the incision. Expressed proportionally rather than only as mean measurements, these percentages provide a better estimate of the location of the LFCN in relation to patient size and thus are useful when operating in this region. Am J Orthop. 2007;36(3):143-146.
148	Subtalar Dislocation in an 8-Year-Old Boy: A Rare Clinical Presentation CPT Jeffrey R. Giuliani, MC; CPT Brett A. Freedman, MC; MAJ Scott B. Shawen, MC; and LTC Gerald L. Farber, MC Abstract not available. Introduction provided instead. Subtalar dislocation is a rare condition in adults, but it is rare yet in patients less than 18 years old. In the few reports of pediatric subtalar dislocations, both adolescents and young adults have been included in the patient series.1-5 The youngest patient with a true dislocation reported to this point has been a 13-year-old girl. All the previously reported cases were secondary to trauma, and many had associated peritalar or ankle fractures. In the majority of cases reported, the distal tibial and fibular physes would likely have been closed. As a result, hyper-inversion forces were prevented from dissipating through the physis and instead were concentrated at the subtalar joint. In younger patients, the open physes about the ankle are believed to act as the path of least resistance, fracturing prior to subtalar dislocation. At the time of writing, isolated subtalar dislocation had not been described in a patient with documented open peritalar physes. This report describes a case in which an 8-year-old boy with open distal physes sustained an isolated traumatic dislocation. Am J Orthop. 2007;36(3):148-151.
153	Incidence of Os Acromiale in Patients With Shoulder Pain Kelton M. Burbank, MD, Mark J. Lemos, MD, Gretchen Bell, BA, and David W. Lemos, MD A prospective case series was undertaken to determine the incidence of os acromiale in patients presenting to an orthopedic clinic with shoulder pain during a 6-month period. Ninety-three shoulders in 88 consecutive patients were evaluated by history, physical examination, and radiographs. Radiographs included anteroposterior, scapular Y, and axillary views in all patients. Based on history and physical examination, no patient was given a primary diagnosis of os acromiale. However, when the plain films were specifically reviewed for this entity, it was present in 6 (6.82%) of the 88 patients. It was seen on the axillary view in each case. Five (83.3%) of the 6 patients had been given a diagnosis of either impingement or rotator cuff tear based on physical examination. Os acromiale is an infrequent but not rare entity that must be kept in mind when evaluating patients with shoulder pain, as failure to recognize an os acromiale may negatively influence treatment results. An axillary view should be obtained when evaluating patients with shoulder pain. Am J Orthop. 2007;(3):153-155.
158	Outsourcing Your Billing Jennifer A. O’Brien, MSOD Abstract not available. Am J Orthop.2007;(3):158-161.
165	Combined Technique for Draining Septic Arthritis of the Pediatric Hip Matthew J. Smith, MD, Richard A. White, MD, and Barry J. Gainor, MD Recent literature suggests that, in older children, acute cases of septic arthritis may be treated with aspiration and intravenous antibiotics. However, when surgical decompression is required, the technique described in this report has several advantages. It can be performed with an incision of approximately 1 to 2 inches and a posterior stab wound of <1 cm; it preserves anatomic planes and poses less risk to the circumflex femoral vessels (as with the anterior approach); and it allows fluid to drain when the patient is supine (as with the posterior approach). Am J Orthop. 2007;(3):165-166.

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2	Introduction: New Treatment Paradigms in Rheumatoid Arthritis Chaim Putterman, MD Abstract not available.
4	Introduction: New Treatment Paradigms in Rheumatoid Arthritis Chaim Putterman, MD Abstract not available.
8	Selective T-Cell Costimulation Modulation: A New Approach to Treating Rheumatoid Arthritis Vibeke Strand, MD Abstract not available.
15	Safety and Efficacy of the Biologic Response Modifiers Joseph Markenson, MD Abstract not available.

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