56 Infectious Destruction of the Wrist
56.1 Patient History Leading to the Specific Problem
A 68-year-old man suffered from pain in his left thumb for years because of advanced osteoarthritis of the first carpometacarpal (CMC I) joint. Diabetes mellitus, peripheral arterial occlusive disease, and heavy smoking were preexisting conditions. Therefore, in a private practice, an operative procedure such as a resection arthroplasty was avoided and a steroid injection in the painful CMC joint was performed. One month later, the patient presented in another department for general surgery with wrist pain and with a general but unspecific feeling of sickness. There was no fever. Laboratory diagnostics revealed a mild increase in CRP (C-reactive protein) and no leukocytosis. X-rays did not show any bony disorders beside the preexisting osteoarthritis of the CMC joint (▶Fig. 56.1). The patient was discharged with the advice for a symptomatic treatment. Five months later, the patient presented in the hospital and workplace of the authors with increasing pain and extensive swelling of the wrist (▶Fig. 56.2).
Fig. 56.1 Initial X-ray image of the left wrist captured 1 month after steroid injection in the first carpometacarpal joint.
56.2 Anatomic Description of the Patient’s Current Status
In the presented case, a steroid injection led to a chronic infection of the bone with a slow but relentless destruction of the wrist and of the distal radioulnar joint.
Generally, a deep injection in a joint is difficult to treat. A sterile setting is strongly recommended if the operative procedure is indispensable. Otherwise, germs will find the synovial fluid and only few intra-articular immune cells as the perfect breeding ground. Potentially, immunosuppression caused from steroids and a general condition of reduced resistance due to diabetes facilitated the unfaithful course in addition in this case.
A sufficient treatment of the infection and the bacterial colonization is now required. It is necessary to address the challenge of extensive bone loss after radical debridement. Thereby, total wrist arthrodesis is difficult due to loss of bone stock. Furthermore, the destructed distal radioulnar joint also has to be treated.
Fig. 56.2 (a, b) X-ray images of the left wrist 5 months after steroid injection in the first carpometacarpal joint. A severe destruction of all wrist joint surfaces with advanced osteolysis was detected.
56.3 Recommended Solution to the Problem
First, radical debridement with removal of infectious tissue, necrotic bone, and destructed articular surfaces is necessary. Subsequently, local and systemic antibiotic therapy for 6 weeks is demanded. Meanwhile external fixation of the wrist is applied. A huge bony defect remains, and total wrist fusion with interposition of a huge bone graft is required.
In wrist fusion, the carpal height has to be reconstructed to maintain the force transmission of the forearm. Therefore, the resulting bone defect has to be reconstructed. A postinfectious site always comes along with necrosis due to limited micro-perfusion and has the risk of a rest contamination. Hence, we recommend free microvascular bone flaps in bone defects of more than 4 cm instead of nonvascularized bone grafts. A vascularized fibular autograft is not adequate because of the narrow contact surfaces of the metacarpal bases that have to be included into the wrist arthrodesis in this case. Therefore, a deep circumflex iliac artery (DCIA) bone flap is used for total wrist fusion in combination with a conventional AO wrist fusion plate that bridges the former CMC III joint.
The distal radioulnar joint is treated by resection arthroplasty. In this case, a Darrach procedure is suitable because of the extended destruction of the ulnar head.
56.3.1 Recommended Solution to the Problem
• Radical debridement with removal of necrotic bone and destructed joint surfaces.
• External fixation of the wrist is applied, and local and systemic antibiotic therapy is demanded.
• Wrist arthrodesis with replacement of the lost bone and restoration of carpal height in an interval of approximately 6 weeks.
• A post infectious bone defect of more than 4 cm is reconstructed by a free microvascular bone graft.
• In the presented case, a DCIA bone flap is adequate.
• Darrach’s procedure is used for the distal radioulnar joint.
• We recommend implant removal after ensured radiological consolidation.
56.4 Technique
The wrist is debrided. In advanced cases, a resection of the whole carpus is often unavoidable. Mostly, bony infection of the wrist is caused by the Staphylococcus species. The defected is filled with an antibiotic carrier; typically, gentamicin chains are used. An interval of local and systematic antibiotic therapy of 6 weeks is frequently recommended in the literature. Meanwhile, external fixation is used (▶Fig. 56.3), and the ulnar head is resected.
Wrist arthrodesis in the interval is realized by a DCIA bone flap. Therefore, the patient is placed in the supine position with the ipsilateral hip slightly elevated. The inguinal ligament and the femoral vessels are marked for orientation. Incision is made just above and parallel to the inguinal ligament. Superficial circumflex iliac artery (SCIA) and DCIA are identified at their origin. DCIA is traced in the level of fascia transversalis toward the anterosuperior iliac spine. Dissection should proceed laterally, the lateral cutaneous nerve should be preserved. The iliac crest is encountered; superficial muscles are divided from their iliac crest insertion, exposing the iliacus muscle with the overlaying vessels. Now osteotomy can be performed. In this case, a full-thickness graft is required. Closure is performed in layers over suction drains (▶Fig. 56.4).
After de novo debridement, graft is inserted in the resection cavity and the carpal height is restored. Wrist fusion and osteosynthesis are performed using a standard AO wrist fusion plate (Synthes, West Chester, PA, United States). The CMC III joint has to be incorporated in the arthrodesis in this case. After supply of the hard tissue, the graft is hooked up to the recipient vessels (ramus carpalis dorsalis, a side branch of radial artery and vein) in end-to-end technique using the microscope.
