Surgical Solution for Total Carpectomy due to Destructive Wrist Pan-Osteomyelitis Using a Free Femoral Condyle Osteocutaneous Flap for Wrist Arthrodesis

Abstract

Osteomyelitis of the hand is rare, even more so in the carpal bones. Patients with rheumatoid arthritis (RA) have a higher infection rate overall, and up to a 14-fold increase in the incidence of septic arthritis of the hand. The destruction of immunologic barriers, such as cartilage and joint capsules, as well as the use of immunosuppressive medications will have an impact on the higher incidence of articular infections and osteomyelitis in these patients. Infection in these cases is often overlooked because of the similarity of presentation to an acute event of RA. When osteomyelitis is present, rapid and aggressive treatment should be given. Surgical debridement, lavage, and excision of necrotic bone is the best choice, followed by cemented antibiotic impregnated spacer to resolve the acute scenario. Vascularized bone grafts (VBG) can then be used for a definitive solution, as these have great biologic properties that increase the possibility of a good outcome. We hereby present a report of a wrist arthrodesis, using a free medial femoral condyle VBG for the treatment of destructive osteomyelitis of the carpal bones in a female patient with RA.

Keywords: Carpal Bones; Cemented Spacer; Osteomyelitis; Rheumatoid Arthritis; Vascularized Bone Graft.

Fig. 1

Clinical pictures of the patient’s wrist during her first visit to our office. It could be noticed that there was severe increase in volume accompanied by erythema in its volar aspect.

Fig. 2

Presurgical X-rays showing an important decrease in bone mineral density as well as ground glass opacity in all the carpal bones, bases of 2nd to 5th metacarpal bones, and in the distal epiphysis of radius and ulna, suggestive of osteomyelitis.

Fig. 3

Intraoperative image of the first intervention showing a purulent secretion in the volar and dorsal aspects of the wrist.

Fig. 4

X-rays of the wrist after the first surgical procedure, showing the subtotal carpectomy (trapezium and part of trapezoid remaining) and the colocation of a cement spacer with antibiotic.

Fig. 5

( A ) The wrist area after the removal of the cement spacer is seen showing a vascularized pseudomembrane in the resulting space. ( B ) The surgical field is seen identifying in blue extensor pollicis longus (EPL), in green extensor carpi radialis brevis (ECRB), in red extensor carpi radialis longus (ECRL), and the dorsal branch of the radial artery is marked with an orange Surgiloop.

Fig. 6

( A ) The medial approach to the distal third of the thigh is seen between the vastus medial muscle (red arrow) and the sartorius tendon (blue arrow) with a green arrow identifying the descending genicular artery. ( B ) The bone portion of the 3 × 3-cm flap identified by a clamp irrigated by the osteoarticular branch (green arrow) as well as the saphenous branch (red arrow) along with the skin portion of the flap at the bottom of the image is seen originating from the descending genicular branch (blue arrow).

Fig. 7

( A ) Transoperative X-rays after fixation of the flap with a locking anatomical plate. ( B ) Skin monitor already sutured.

Fig. 8

Clinical images of the surgical approach of the knee, appreciating an adequate scar 3 months after the intervention.

Fig. 9

Three months postsurgical X-rays of the knee show adequate bone density and filling in the region where the graft was taken without signs of fragility.

Fig. 10

X-rays 3 months after the surgical procedure in which adequate consolidation of proximal predominance is seen.

Fig. 11

Postoperative clinical image in which a complete compound fist is seen at 3 months postoperatively.