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

Osteomyelitis - Vascularized Bone Graft - Carpal Bones - Rheumatoid Arthritis - Cemented Spacer

Publikationsverlauf

Artikel online veröffentlicht:
29. September 2021

• References

• 1 Ngo ST, Steyn FJ, McCombe PA. Gender differences in autoimmune disease. Front Neuroendocrinol 2014; 35 (03) 347-369
• 2 Smolen JS, Aletaha D, Barton A. et al. Rheumatoid arthritis. Nat Rev Dis Primers 2018; 4 (01) 18001
• 3 Alamanos Y, Drosos AA. Epidemiology of adult rheumatoid arthritis. Autoimmun Rev 2005; 4 (03) 130-136
• 4 Cantley M, Smith M, Haynes D. Pathogenic bone loss in rheumatoid arthritis: mechanisms and therapeutic approaches. Int J Clin Rheumatol 2009; 4 (05) 561-582
• 5 Raven EE, van den Bekerom MP, Beumer A, van Dijk CN. Radiocarpal and midcarpal instability in rheumatoid patients: a systematic review. Open Orthop J 2015; 9 (01) 246-254
• 6 Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg 1991; 87 (02) 290-298
• 7 Mehta B, Pedro S, Ozen G. et al. Serious infection risk in rheumatoid arthritis compared with non-inflammatory rheumatic and musculoskeletal diseases: a US national cohort study. RMD Open 2019; 5 (01) e000935
• 8 Doran MF, Crowson CS, Pond GR, O’Fallon WM, Gabriel SE. Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum 2002; 46 (09) 2287-2293
• 9 Goldenberg DL. Infectious arthritis complicating rheumatoid arthritis and other chronic rheumatic disorders. Arthritis Rheum 1989; 32 (04) 496-502
• 10 Holland C, Jaeger L, Smentkowski U, Weber B, Otto C. Septic and aseptic complications of corticosteroid injections: an assessment of 278 cases reviewed by expert commissions and mediation boards from 2005 to 2009. Dtsch Arztebl Int 2012; 109 (24) 425-430
• 11 Wronka KS, Sinha A. Calcaneal osteomyelitis following steroid injection for plantar fasciitis: a case report. Foot Ankle Spec 2012; 5 (04) 253-255
• 12 Mattos D, Ko JH, Iorio ML. Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis. Microsurgery 2019; 39 (01) 32-38
• 13 Pinder R, Barlow G. Osteomyelitis of the hand. J Hand Surg Eur Vol 2016; 41 (04) 431-440
• 14 Gill P, Lambah A. Osteomyelitis of the hand. Trauma 2013; 16 (01) 48-50
• 15 Wong VW, Higgins JP. Medial femoral condyle flap. Plast Reconstr Surg Glob Open 2016; 4 (08) e834
• 16 Yajima H, Kobata Y, Tomita Y, Kawate K, Sugimoto K, Takakura Y. Ankle and pantalar arthrodeses using vascularized fibular grafts. Foot Ankle Int 2004; 25 (01) 3-7
• 17 Capanna R, Campanacci DA, Belot N. et al. A new reconstructive technique for intercalary defects of long bones: the association of massive allograft with vascularized fibular autograft. Long-term results and comparison with alternative techniques. Orthop Clin North Am 2007; 38 (01) 51-60, vi
• 18 Doi K, Akino T, Shigetomi M, Muramatsu K, Kawai S. Vascularized bone allografts: review of current concepts. Microsurgery 1994; 15 (12) 831-841
• 19 González del Pino J, Bartolomé del Valle E, Graña GL, Villanova JF. Free vascularized fibular grafts have a high union rate in atrophic nonunions. Clin Orthop Relat Res 2004; ; ( (419) 38-45
• 20 Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010; 41 (01) 27-37
• 21 Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting. J Trauma 1995; 38 (06) 910-914
• 22 Rodríguez-Vegas JM, Delgado-Serrano PJ. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities. J Plast Reconstr Aesthet Surg 2011; 64 (04) 515-527
• 23 Kazmers NH, Thibaudeau S, Steinberger Z. Scott Levin L. Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: a systematic review. Microsurgery 2018; 38 (03) 328-343
• 24 Katz RD, Parks BG, Higgins JP. The axial stability of the femur after harvest of the medial femoral condyle corticocancellous flap: a biomechanical study of composite femur models. Microsurgery 2012; 32 (03) 213-218
• 25 Endara MR, Brown BJ, Shuck J, Bachabi M, Parks BG, Higgins JP. Torsional stability of the femur after harvest of the medial femoral condyle corticocancellous flap. J Reconstr Microsurg 2015; 31 (05) 364-368
• 26 Iorio ML, Masden DL, Higgins JP. The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg Am 2011; 36 (10) 1592-1596
• 27 Boretto JG, Altube G, Gallucci GL, Narvaez HR, De Carli P. Femoral osteonecrosis after medial femoral condyle bone graft harvest. Plast Reconstr Surg Glob Open 2018; 6 (06) e1792
• 28 Iorio ML, Moran SL. Ch. 39. Medial femoral condyle flap. In: Chung KC and Moran SL, eds. ASSH Surgical Anatomy: Flap Reconstruction. 1st ed. Chicago: American Society for Surgery of the Hand 2018: 284-295
• 29 Kumta S, Warrier S, Jain L, Ummal R, Menezes M, Purohit S. Medial femoral condyle vascularised corticoperiosteal graft: a suitable choice for scaphoid non-union. Indian J Plast Surg 2017; 50 (02) 138-147
• 30 Taniguchi Y, Yoshida M, Doi N, Tamaki K, Tamaki T. Vascularized fibular osteocutaneous grafts in the treatment of severely infected wrist arthritis. J Reconstr Microsurg 2002; 18 (02) 71-75
• 31 McKay P, Formby P, Dickens J, Gibson M. Osteomyelitis and septic arthritis of the hand and wrist. Curr Orthop Pract 2010; 21 (06) 542-550