Randall E. Marcus

Management of Open Fractures and Subsequent Complications

Early, systemic, wide-spectrum antibiotic therapy is necessary for the treatment of open fractures. The bead pouch technique delivers antibiotics locally and prevents secondary wound contamination. The open fracture wound should be thoroughly débrided. To avoid the complication of gas gangrene, the wound should not be closed. Extensive soft-tissue damage may necessitate the use of local or free flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and the characteristics of the injury. Early bone grafting and supplemental procedures may be needed to achieve healing. Management of the infected open fracture is based on radical débridement, skeletal stabilization, microbial-specific antibiotics, soft-tissue coverage, and reconstruction of bone defects.

Age-Based Outcomes of Cheilectomy for the Treatment of Hallux Rigidus:

The results of cheilectomy, performed on 67 consecutive patients with hallux rigidus resulting in primary extra-articular symptoms are presented. Four patients who underwent subsequent fusion were rated as failures. Follow-up evaluation, averaging 65 months (28–117) on 53 additional patients available for follow-up, revealed an average AOFAS score of 80. with 91% of the patients stating that they were currently better than before surgery. There was a statistically significant higher mean score (89) in patients over 60 years of age at the time of surgery. There were no differences between other age groups, preoperative grade, duration of symptoms, or length of follow-up. Cheilectomy should be the treatment of choice for hallux rigidus with predominantly extra-articular symptoms, especially in patients over 60 years of age.

Lipopolysaccharide found in aseptic loosening of patients with inflammatory arthritis

Aseptic loosening of orthopaedic implants occurs in the absence of clinical signs of infection. Nevertheless, bacterial endotoxins derived from subclinical infections, systemic sources, or the implant manufacturing process may contribute to aseptic loosening. Also, the rate of implant infection is greater in patients with inflammatory arthritis than in patients with osteoarthritis. We hypothesized that lipopolysaccharide, the classic endotoxin derived from gram-negative bacteria, is more prevalent in periprosthetic tissue surrounding aseptically loose implants in patients with inflammatory arthritis than in patients with osteoarthritis. To test this, we used a modified Limulus amebocyte assay not affected by β-glucan-like molecules in mammalian tissues. Lipopolysaccharide rarely was detected in periprosthetic tissue from patients with osteoarthritis and aseptic loosening (one of six patients). In contrast, lipopolysaccharide was detected despite the absence of any clinical signs of infection in peri-prosthetic tissue from all four patients with inflammatory arthritis (rheumatoid arthritis, juvenile rheumatoid arthritis, and systemic lupus erythematosus). Lipopolysaccharide also was detected in two patients with gram-negative infections, who were included as positive control subjects. Endotoxins derived from low-grade or systemic bacteremia may be important contributors to aseptic loosening particularly in patients with autoimmune conditions such as inflammatory arthritis.

Erythropoiesis in Patients Stimulated with Erythropoietin: The Relevance of Storage Iron

Background and Objectives: The clinical importance of iron-restricted erythropoiesis in erythropoietin (EPO)-stimulated patients is controversial. Materials and Methods: We therefore reviewed 70 patients randomized into clinical trials of aggressive autologous donation and oral iron supplementation, with or without recombinant human EPO therapy. Results: Nineteen (27%) iron-depleted patients produced 5.4±2.8 ml RBC/kg compared to 4.8±2.3 ml RBC/kg (nonsignificant) in iron-replete patients due to endogenous EPO (placebo group) stimulation. EPO-treated iron-depleted patients produced 20% less RBC than iron-replete patients (8.23±3.3 vs. 10.2±4.0, p = 0.066). RBC volume expansion correlated with initial storage iron only in iron-replete patients who received EPO therapy. Conclusion: Initial storage iron status is a marginally important limitation to EPO-mediated erythropoiesis in the setting of oral iron supplementation. Strategies to maintain plasma transferrin saturation with intravenous iron therapy may be desirable to improve the erythropoietic response to EPO in this setting.

Triple arthrodesis for diabetic peritalar neuroarthropathy

From 1963 to 1990, the senior authors (R.E.M. and K.G.H.) performed eight triple arthrodeses in seven patients with diabetes mellitus with sensory loss in the lower extremities. By clinical and roentgenographic examination, all patients were diagnosed with peritalar neuroarthropathy before surgery. All patients underwent a two-incision triple arthrodesis with internal fixation. Patient follow-up averaged 44 months and included repeat physical examinations and radiographs. All patients went on to clinical union and were satisfied with the procedure. One patient had prolonged wound drainage that resolved with antibiotic therapy; another had a residual rocker-bottom deformity and plantar ulceration that resolved after modification of custom shoe wear. We believe comprehensive management of diabetic peritalar neuroarthropathy can include surgical arthrodesis of the involved joints. The disease process and surgical indications are discussed.

Ankle arthrodesis by chevron fusion with internal fixation and bone-grafting.

We evaluated the results in thirteen patients with disabling tibiotalar arthritis who underwent a new operation for ankle fusion for relief of pain. The procedure in all of these patients was a chevron (pitched-roof) tibiotalar osteotomy and excision of the joint. A bilateral approach to the ankle joint was used and the arthrodesis was supplemented by internal fixation and a tibial onlay graft applied medially. There were few complications, none of them of major importance. The after-care required only immobilization in a short cast. All but one patient had a solid fusion. The final result was a normal-looking ankle with good function.

Posterior Hip Dislocations: A Cadaveric Angiographic Study

Avascular necrosis (AVN) of the femoral head after a traumatic posterior hip dislocation (Thompson and Epstein type I) has been hypothesized to occur due to changes in blood flow. However, to the best of our knowledge of the English literature, a human cadaveric angiographic study has never been performed to delineate these vascular changes. Six fresh frozen human cadavers were used to examine the effects of posterior hip dislocation on the extraosseous and intraosseous blood supply to the femoral head and neck. After a forceful posterior hip dislocation was performed on the cadavers, the proximal vessels were injected with a radioopaque colored latex liquid polymer (Microfil) and examined under cinefluoroscopy. The contra lateral hips were used as controls and were examined in a similar manner. Both hips of the cadavers were harvested, and a macroscopic and microscopic examination was performed. The cine-fluoroscopic examination delineated the dynamic effects of posterior dislocation on the surrounding vasculature. Filling defects were most notable at the junction of the external iliac and common femoral arteries. Filling defects were also present in the circumflex vessels. Compared to controls, the common femoral and circumflex vessel filling defects were statistically significant (p < 0.004). These defects were secondary to an apparent stretching and twisting of the artery caused by the pull and rotation of the dislocated hip. A number of collateral vessels from the gluteal arteries were also demonstrated on fluoroscopic examination. The macro and microscopic examination did not show a qualitative or a quantitative difference in the amount of latex present in the dislocated and control groups. Based on the results of this study, changes in the extraosseous blood flow to the dislocated hip do occur. The vessels that appear to be most affected by the dislocation are the common femoral and circumflex vessels. However, these extraosseous changes do not consistently result in changes in the intraosseous blood flow possibly due to collateral circulation. Relocating the femoral head in a traumatic posterior hip dislocation may provide earlier blood flow to the femoral head by relieving tension across the femoral and circumflex vessels. Delayed relocation could contribute to the development of AVN in the femoral head by not only inducing immediate ischemia at the time of injury but by also producing a progressive and delayed form of arterial damage in the femoral and circumflex vessels. AVN may not be an absolute outcome of posterior hip dislocations due to preexisting collateral circulation and/or the preservation of the femoral circumflex vessels.

Clinical Outcome of Surgical Treatment of the Symptomatic Accessory Navicular

Background: When conservative treatment fails to provide relief for a symptomatic accessory navicular, surgical intervention may be necessary. Numerous studies have been published, reporting the results of the traditional Kidner procedure and alternative surgical techniques, all of which produce mostly satisfactory clinical outcomes. The purpose of this study was to report the clinical results, utilizing the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, of surgical management for symptomatic accessory navicular with simple excision and anatomic repair of the tibialis posterior tendon. Methods: The authors retrospectively reviewed the results of 13 consecutive patients (14 feet) who underwent surgical treatment for symptomatic accessory navicular. The patients ranged in age from 16 to 64 years (average, 34.1 years; mean, 28.2 years) at the time of surgery. All patients had a type II accessory navicular. The average follow-up of the patients involved in the study was 103.4 months (range, 45–194 months). The AOFAS Midfoot Scale was utilized to determine both preoperative and postoperative clinical status of the 14 feet included in the study. Results: The average preoperative AOFAS score was 48.2 (range, 20–75; mean, 38.8). The average postoperative AOFAS score was 94.5 (range, 83–100; mean, 94.3). At last follow-up, 13 of 14 feet were without any pain, no patients had activity limitations, and only two of 14 feet required shoe insert modification. Postoperatively, no patients had a clinically notable change in their preoperative midfoot longitudinal arch alignment. All of the patients in the study were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances. Conclusions: When conservative measures fail to relieve the symptoms of a painful accessory navicular, simple excision of the accessory navicular and anatomic repair of the posterior tibialis tendon is a successful intervention. Overall, the procedure provides reliable pain relief and patient satisfaction. In the current study, the clinical status of each patient improved significantly postoperatively, quantified utilizing the AOFAS Midfoot Scale.

Effect of autologous blood donation in patients undergoing elective spine surgery.

Autologous blood predeposit before elective surgery is a rapidly expanding transfusion practice. A 3–year analysis of an autologous blood predeposit program was conducted to assess its impact on orthopaedic spine surgery. It was concluded that, first, autologous blood donation has resulted in a reduction of homologous blood transfusions in patients undergoing elective spine procedures from 26% to 13% (P=.02). Second, autologous blood preoperative donation in elective spine surgery has increased significantly, so that autologous blood as an alternative to homologous blood transfusion now represents a standard of practice for elective spine surgery at the institution included in the study. Third, limitations of preoperative autologous blood procurement suggest that application of additional blood conservation interventions as alternatives to homologous blood would be important contributors to achieving “bloodless” surgery in this setting.

Clinical outcome of tibiotalar arthrodesis utilizing the chevron technique

Tibiotalar arthrodesis remains the gold standard reconstructive procedure for the treatment of disabling ankle arthritis. The purpose of this study was to review the clinical results of tibiotalar arthrodesis utilizing the chevron fusion technique. The results of 46 consecutive patients who underwent ankle arthrodesis utilizing the chevron technique were reviewed. The etiology of the tibiotalar arthritis was posttraumatic in 29 of 46 patients. Of the remaining 17 patients, seven had osteoarthritis, five had talar osteonecrosis, two had rheumatoid arthritis, one had hemophilic arthropathy, one had gouty arthropathy, and one had unrecognized chronic osteomyelitis. Three patients had prior hind-foot arthrodeses, and two patients had bilateral ankle fusions at last follow-up. All patients were followed for a minimum of 2 years. Of the 46 patients, 41 were available for review, with an average follow-up of 7.3 years (range, 2–20 years). Twelve patients had greater than 10-year follow-up. The Mazur ankle score was calculated for all 41 patients. The average Mazur ankle score for the 41 patients available for review was 72.8, out of a maximum possible score of 90. Eighteen patients had excellent results, 11 patients had good results, five patients had fair results, and seven patients had poor results. The most common reasons for fair or poor results were symptomatic subtalar arthritis and multiple medical comorbidities. All patients with postoperative symptomatic subtalar arthritis had preoperative radiographic evidence of subtalar arthrosis. Of the 12 patients with greater than 10-year follow-up, nine had excellent or good results, and an average Mazur ankle score of 76.6. All patients with either prior hindfoot arthrodeses or bilateral ankle fusions had excellent or good results. Of the 41 arthrodeses included in the study, 38 (38/41, 93%) went on to clinical and radiographic union. The chevron technique provides a predictable method to obtain fusion of the tibiotalar joint. Most patients can expect excellent or good results. In the current study, 90% (37/41) of patients were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances.