PMC6149196_01
Macroscopic findings of the patient's hand.. (A) Photograph on admission showing that the wound was still open and purulent discharge was present.. (B) After soft tissue debridement. The proximal phalangeal joint cartilage was black-pigmented, but we found no tooth mark in the bone or cartilage at the inoculation site.. (C) Head of the proximal phalanx was resected. The proximal phalanx intramedullary canal was black-pigmented.
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The wound was still open and purulent discharge was seen (Fig. 1A). We immediately performed soft tissue debridement and irrigation, and intraoperatively the PIP joint cartilage and proximal phalanx intramedullary canal were black-pigmented; however, we could not find a tooth mark in the bone or cartilage at the inoculation site (Fig. 1B,C).
Magnetic resonance images at the first visit. Magnetic resonance images indicated osteomyelitis of the proximal phalanx.. (A) T1-weight image.. (B) T2-weight image.. (C) T2 STIR image showing speckled intensity.
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Blood laboratory testing revealed a white blood cell count of 11,630/mm3 and C-reactive protein level of 1.94 mg/dl, and magnetic resonance imaging revealed osteomyelitis of the proximal phalanx (Fig. 2).
(A) The first step: Proximal interphalangeal joint resection. The wound was left open following debridement and handmade external fixation was applied. (B) The second step: An antibiotic-infused cement spacer was placed in the bone defect. (C) The wound was covered with an island flap from the ring finger. (D) The third step: The proximal interphalangeal joint was fixed with a plate and iliac bone grafting was performed.
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The debridement including the distal half of the proximal phalanx and base of the middle phalanx was done, which resulted in about 2 cm of bony gap between proximal phalanx and middle phalanx (Figs. 3A and 4 A). At the second step three weeks later, we performed an island flap from the ring finger for soft tissue coverage and left a cement spacer infused with antibiotics (panipenem/betamipron) in the defect of the PIP joint then applied an external fixator to preserve bone length (Figs. 3B,C, 4 B). At the third stage four weeks after the second operation, we removed the cement spacer and fixed the PIP joint at 40  of flexion with a bent dorsal plate (modular hand T-plate, Synthes, Paoli, PA), then filled the defect with cancellous bone from the iliac crest (Figs.3D, 4 C).
(A) Post first step X-ray. After debridement and handmade external fixation was applied. (B) Post second step X-ray. Cement spacer was interposed with external fixation. (C) Post third step X-ray. The proximal interphalangeal joint was fixed the PIP joint at 40  of flexion with a bent dorsal plate and iliac bone grafting was performed. (D) (E) Radiograph 32 months after the last operation showing that the bone had united in a bent configuration at the same angle set at the final stage of surgery. The hardware was already removed.
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The debridement including the distal half of the proximal phalanx and base of the middle phalanx was done, which resulted in about 2 cm of bony gap between proximal phalanx and middle phalanx (Figs. 3A and 4 A). At the second step three weeks later, we performed an island flap from the ring finger for soft tissue coverage and left a cement spacer infused with antibiotics (panipenem/betamipron) in the defect of the PIP joint then applied an external fixator to preserve bone length (Figs. 3B,C, 4 B). At the third stage four weeks after the second operation, we removed the cement spacer and fixed the PIP joint at 40  of flexion with a bent dorsal plate (modular hand T-plate, Synthes, Paoli, PA), then filled the defect with cancellous bone from the iliac crest (Figs.3D, 4 C). At 32 months after the Masquelet procedure, the angle of the PIP joint was unchanged from the angle at the time of arthrodesis, and there were no problems related to the island flap (Figs. 4D,E, 5 ).
Photographs of the healed finger at 32 months after the last operation.
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At 32 months after the Masquelet procedure, the angle of the PIP joint was unchanged from the angle at the time of arthrodesis, and there were no problems related to the island flap (Figs. 4D,E, 5 ).