MAY 2009 VOLUME XXXVIII NUMBER 5 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

82	Simultaneous Solitary Glomus Tumors in Nonadjacent Digits Todd R. Rimington, MD, and Charles S. Lefton, MD Dr. Rimington is Resident, Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC. Abstract not available. Introduction provided instead. The glomus tumor is a rare tumor that arises from the glomus apparatus of the dermal retinacular layer of the skin.1 This tumor has solitary and multiple forms. Solitary tumors are commonly found in the distal phalanx in a paraungual or subungual location. They present with a classic triad of paroxysmal pain, pinpoint tenderness, and cold hypersensitivity.1 Multiple tumors are extremely rare, are inherited in an autosomal-dominant pattern, and can have involvement outside the hand. Multiple tumors are commonly asymptomatic, but the multiple form can have mixed symptomatic and asymptomatic tumors. Histopathologic characteristics can be used to differentiate the solitary and multiple forms. To our knowledge, simultaneous solitary glomus tumors in nonadjacent digits have not been reported in the literature. In this article, we describe the case of a woman in her early 40s with clinical, radiographic, and histologic findings for simultaneous solitary glomus tumors in nonadjacent digits of the hand. The authors obtained the patient’s written informed consent for print and electronic publication of her case report. Am J Orthop. 2009;38(5):E82-E84.
85	A Rare Case of Chondromyxoid Fibroma of the Scapula Jay B. Jani, MD, Kathleen S. Beebe, MD, Meera Hameed, MD, and Joseph Benevenia, MD Dr. Jani is Fellow, Division of Musculoskeletal Oncology, Department of Orthopaedics, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey. Abstract not available. Introduction provided instead. Chondromyxoid fibroma (CMF) is a rare benign tumor, apparently derived from cartilage-forming connective tissue. The name is highly descriptive of this distinctive tumor and has gained acceptance.1 The entity was first described in 1948 by Jaffe and Lichtenstein,2 who presented 8 cases and emphasized the danger of mistaking this benign neoplasm for a malignant lesion, chondrosarcoma in particular. Approximately two thirds of the recorded cases of this tumor have been in the long tubular bones and one third in the proximal tibia.1,3,4 A scapular origin of this tumor is exceedingly rare.1,5-10 We report the case of a 13-year-old girl with chondromyxoid fibroma of the scapula. This case is of interest because of the rarity and unusual location of the tumor. The authors have obtained the patient’s guardian’s written informed consent for print and electronic publication of the case report. Am J Orthop. 2009;38(5):E85-E88.
89	Malignant Peripheral Nerve Sheath Tumor of the Lumbar Spine Brent K. Ogawa, MD, David L. Skaggs, MD, and Robert M. Kay, MD Dr. Ogawa is Fellow, Roger A. Mann Foot and Ankle Fellowship, Oakland, California.DC. Abstract not available. Introduction provided instead. Malignant peripheral nerve sheath tumors (MPNSTs) are rare in children. MPNSTs arise from peripheral nerves or show differentiation of nerve sheath elements, including Schwann cells, fibroblasts, and perineural cells. The term malignant peripheral nerve sheath tumor has replaced older terms, such as malignant schwannoma, neurofibrosarcoma, and neurogenic sarcoma. Incidence of MPNST ranges from 2% to 13%.1 MPNSTs account for approximately 5% to 10% of all soft-tissue sarcomas. Depending on its location and amount of nerve involvement, MPNST can present as a painful or painless mass. MPNSTs that arise from major nerves can cause sensory and motor symptoms, such as pain, paresthesia, and weakness. Most arise in association with major nerve trunks, such as the brachial or sacral plexus or sciatic nerve. Approximately 50% arise in the trunk, 30% in extremities, and 20% in the head and neck.2 Compared with patients who do not have neurofibromastosis type 1 (NF-1), patients with NF-1 have a central distribution of primary tumors.3 An association between MPNST and NF-1 has been well documented.1-20 Patients with NF-1 and MPNST tend to be younger (28.7 years) than patients who have MPNST without NF-1 (39.7 years).4 Prior radiation therapy has also been well documented as an important risk factor in development of MPNST.3,7,8,16,18 Wong and colleagues7 reported that, in 10% of their patients, radiation given for prior unspecified tumors induced MPNST. MPNSTs often are difficult to diagnose and behave aggressively. Treatment includes wide surgical resection. Adjuvant therapy is advocated by some authors, though the results are mixed. Tumor size, patient age, tumor necrosis, and presence of neurofibromatosis can negatively affect survival. Despite appropriate treatment, recurrence is high and prognosis poor. We describe the case of a lumbar-spine MPNST that presented as chronic knee pain in a boy. The patient had many of the typical signs and symptoms of an intraspinal tumor, which facilitated appropriate diagnosis and treatment. Such signs and symptoms should be sought in children who present with neurogenic pain. Am J Orthop. 2009;38(5):E89-E92.
93	Rare Extraskeletal Osteosarcoma in the Anterolateral Right Leg of a 37-Year-Old Man Brian E. Walczak, DO, Jeffrey S. Peterson, DO, and Ronald B. Irwin, MD Dr. Walczak is Resident, Department of Orthopedic Surgery, Mount Clemens Regional Medical Center, Mount Clemens, Michigan. Abstract not available. Introduction provided instead. To our knowledge, the case described in this article is the first reported case of extraskeletal osteosarcoma localized to the anterolateral compartment of the leg. Although the location of the tumor in our case is unique, the clinical presentation, diagnosis, pathology, and treatment are consistent with prior reported cases. Here we highlight the unique radiographic and pathologic findings and the support for aggressive neoadjuvant therapy of this aggressive neoplasm. It is our hope that this case report provides a crucial review of the typical reported features of extraskeletal osteosarcoma and its management and raises important questions for future study of this rare neoplasm. The authors have obtained the patient’s written informed consent for print and electronic publication of his case report. Am J Orthop. 2009;38(5):E93-E97.

218	GUEST EDITORIAL—“But the MRI of the Ankle Is Normal...” Glenn B. Pfeffer, MD Dr. Pfeffer, the journal’s Associate Editor for Foot and Ankle, is Director of the Foot and Ankle Center, Cedars-Sinai Medical Center, Los Angeles, California. Abstract not available. Am J Orthop. 2009;38(5):218-219.
222	Effect of Simulated Lateral Process Talus “Fracture Excision” on Its Ligamentous Attachments Phillip Langer, MD, Florian Nickisch, MD, David Spenciner, PE, ScM, and Christopher DiGiovanni, MD Dr. Langer is Assistant Team Physician and Orthopedic Surgeon of the NFL Atlanta Falcons and the NHL Atlanta Thrashers, Atlanta Sports Medicine & Orthopedic Center, Atlanta, Georgia. Recent epidemiologic studies highlight lateral talar process fractures as snowboarder’s fracture or snowboarder’s ankle. Snowboarding is the fastest growing sport worldwide, so lateral talar process fractures are increasing in frequency and mandating a more careful assessment of injury patterns, surrounding tissue involvement, and treatment strategy. In this study, we evaluated the effects of lateral talar process fracture on the footprints of 3 lateral stabilizing ligaments of the ankle and subtalar joint—the lateral talocalcaneal ligament (LTCL), the anterior talofibular ligament (ATFL), and the posterior talofibular ligament (PTFL). The musculotendinous structures from 10 fresh cadaveric limbs were removed and the distal fibula reflected to provide visualization of the lateral talar process and ligamentous attachments. Length and width of the LTCL, ATFL, and PTFL footprints on the lateral process of the talus were measured with calipers before and after removal of a 1-cm3 simulated fracture fragment. Relative changes in the attachment site areas for the 3 ligaments were determined. Mean pre-excision footprint areas were 80.57 mm2 (LTCL), 224.38 mm2 (ATFL), and 394.18 mm2 (PTFL); mean postexcision footprint areas were 2.10 mm2 (LTCL), 194.89 mm2 (ATFL), and 335.18 mm2 (PTFL); and mean decreases calculated as percentages of the original areas were 97.5% ± 3.5% (LTCL), 11.7% ± 13.0% (ATFL), and 14.3% ± 12.3% (PTFL). Removal of a 1-cm3 bony fragment from the lateral talar process involves 3 of the major lateral stabilizing ligaments: approximately 100% of LTCL and approximately 10% to 15% of ATFL and PTFL. Am J Orthop. 2009;38(5):222-226.
227	Rate of Return of Functional Outcome After Open Reduction and Internal Fixation of Unstable Ankle Fractures William T. Obremskey, MD, MPH, Bradley Dart, MD, and Miguel Medina, MD Dr. Obremskey is Associate Professor of Orthopedics, Vanderbilt University, Nashville, Tennessee. In the prospective cohort study reported here, we used the Short Musculoskeletal Function Assessment (SMFA) questionnaire to assess rate of return of functional outcome after open reduction and internal fixation of unstable ankle fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen [OTA/AO] 44B and 44C) at a level II trauma center over the course of 1 year. The entire group of 69 consecutive adults improved significantly (P<.01) on the SMFA Emotional Status and Dysfunction scales from 2 to 4 months and on the Mobility and Daily Activities scales from 2 to 4 months and from 4 to 6 months. There were no significant changes on the Arm/Hand Function and Bother scales. There was a significant effect of age on Mobility, Daily Activities, and Dysfunction, with older patients (≥50 years) obtaining higher (worse) scores. There was no significant effect on patient sex on any of the scales. Patients with 44C fractures (vs 44B fractures) had significantly (P = .05) higher mean Bother scores at 6 months. There were no significant differences arising from presence or absence of a fracture of the medial malleolus. Our SMFA data show that older patients (≥50 years) and patients with 44C fractures had slower return to maximal function and higher Bother scores at 6 months. All groups reached a relatively stable functional outcome by 6 months after injury, but their mobility did not return to population norms over the same period. Am J Orthop. 2009;38(5):227-231.
232	Sacral Stress Fractures in Children Jimmi Mangla, MSurg (Ortho), MBBS, Jeffrey L. Young, MD, Torita Thomas, BS, and Eldin E. Karaikovic, MD, PhD Dr. Mangla is Research Fellow, Department of Orthopaedic Surgery, NorthShore University HealthSystems, Evanston, Illinois. Abstract not available. Am J Orthop. 2009;38(5):232-236.
237	Bilateral Fractures of the Medial Malleoli Without a History of Traumas Christopher A. Looze, BS, Brian Golden, MD, and Kenneth A. Egol, MD Mr. Looze is Medical Student, Department of Orthopaedic Surgery, New York University School of Medicine, New York, New York. Abstract not available. Am J Orthop. 2009;38(5):237-240.
241	Footdrop Without Significant Pain as Late Presentation of Acute Peroneal Compartment Syndrome in an Intercollegiate Football Player David Marcu, MD, William H. Dunbar, MD, and Lee D. Kaplan, MD Dr. Marcu is a resident in Orthopedic Surgery, Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin. Abstract not available. Am J Orthop. 2009;38(5):241-244.
246	E-Prescribing and the Physician Quality Reporting Initiative: Get in While the Getting Is Good! Cheyenne Brinson, MBA, CPA; for KarenZupko & Associates, Inc. Ms. Brinson is Consultant and Speaker, KarenZupko & Associates, Inc., Chicago, Illinois. Abstract not available. Am J Orthop. 2009;38(5):246-248.
249	Open Scapula Resection in Beach-Chair Position for Treatment of Snapping Scapula Amy E. Ross, MD, Brett D. Owens, MD, and Thomas M. DeBerardino, MD MAJ Ross, MD, is Orthopaedic Surgeon, Brian Allgood Army Community Hospital, Seoul, Korea. We describe a technique of resecting the superomedial border of the scapula for treatment of “snapping scapula.” We have performed 5 consecutive open resections with the patient in the beach-chair position, and results have been good. This technique may be of particular benefit in patients who undergo concomitant glenohumeral arthroscopy. Am J Orthop. 2009;38(5):249-251.
252	Posterior Ankle Impingement: Os Trigonum Syndrome Sharik Rathur, MD, Paul D. Clifford, MD, and Cary B. Chapman, MD Dr. Rathur is Musculoskeletal Imaging Fellow, Department of Orthopaedics, Miller School of Medicine, University of Miami, Miami, Florida. Abstract not available. Am J Orthop. 2009;38(5):252-253.

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