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

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.

Prevention of Mandible Fractures in Medication-Related Osteonecrosis of the Jaws: The Role of Virtual Surgical Planning and Computer-Aided Design and Manufacturing in Two Clinical Case Reports

Background: Marginal mandible resection is required to achieve healing in some cases of medication-related osteonecrosis of the jaws (MRONJ). Despite the sparsity of the literature, computer-aided design/computer-aided manufacturing (CAD/CAM) materials may provide superior outcomes for patients with an increased risk of mandible fracture. The aim of this study was to report a digital workflow for surgical interventions to prevent mandible fracture in MRONJ patients. Methods: We present two cases in which virtual surgical planning (VSP) and CAD/CAM surgical guides and reconstruction plates were used to prevent mandible fractures in elderly MRONJ patients submitted for marginal resection. Two osteoporotic patients, aged 73 and 84 years, presented with stage 3 MRONJ of the right mandibular body with inferior alveolar nerve involvement. The unaffected bone height was 6 mm in both cases, implying a high risk of mandible fracture. After preoperative VSP, surgery was performed through a combined intraoral–transbuccal approach. CAD/CAM-customized cutting guides and reconstruction plates were used for the marginal resection of necrotic bone and internal fixation. Results: Complete healing was achieved and the patients remained asymptomatic up to 1 year post-surgery. Conclusions: VSP and CAD/CAM-customized materials facilitated the complete resection of necrotic bone and rigid fixation in MRONJ patients, allowing a simplified approach with shorter operative times, reduced morbidity, and predictable results.

Post COVID-19 invasive mucormycosis and actinomycosis co-infection: a case report

<p>Actinomyces are commensals of human oropharynx and actinomycosis is considered mainly as an endogenous infection that is triggered by a mucosal lesion. Typically, the disease presents as a slowly progressive painless indurated mass evolving into multiple abscesses with draining sinus tracts sometimes expressing a typical yellow exudate with characteristic sulfur granules. The gold standard of diagnosis is histological examination and bacterial culture of the tissue. Most isolates are susceptible to beta lactams and they are the treatment of choice along with surgical management with drainage of abscesses and excision of recalcitrant fibrotic lesions and debridement of necrotic bone tissue. Here we present a case of 37-year-old male patient who has developed severe COVID-19 infection following which he developed invasive mucormycosis followed by actinomycosis. We postulate that the lymphopenia and the use of immunosuppressants used in treatment of COVID-19 lead to mucormycosis and aggressive debridement used as a strategy in treatment of mucormycosis led to colonization of actinomyces leading to cervicofacial actinomycosis.</p>

Biomechanical effect of intertrochanteric curved varus osteotomy on stress reduction in femoral head osteonecrosis: a finite element analysis

Background Intertrochanteric curved varus osteotomy (CVO) has been widely used to remove the necrotic bone away from the weight-bearing portion in the treatment of osteonecrosis of the femoral head (ONFH). However, whether all types of necrosis will benefit from CVO, in terms of the stress level, the effect of different center-edge (CE) angles of acetabulum on stress distribution of necrosis after CVO, and the relationship between the intact ratio and the stress of necrosis, has never been addressed. The purpose of the study was to evaluate the influence of CVO on the stress reduction in necrotic bone using a finite element analysis (FEA) with different CE angles. Methods CVO finite element models of the hip joint were simulated with a lesion of 60°. The osteotomy angles were divided into four configurations (15°, 20°, 25°, and 30°), and three types (A, B, and C1) of lesions were established based on the Japanese Investigation Committee (JIC) classification. In addition, two CE angles (18° and 33°) of acetabulum were considered. The maximum and mean von Mises stress were analyzed in terms of the necrotic bone by a physiological loading condition. Moreover, the correlation of the intact ratio measured in 3D and the stress distribution after CVO was analyzed. Results Stress reduction was obtained after CVO. For type B, the CVO angle was 20° (0.61 MPa), and for type C1, the CVO angle was 30° (0.77 MPa), if the mean stress level was close to type A (0.61 MPa), as a standard. The maximum and mean von Mises stress were higher in the CE angle of 18°models, respectively. The intact ratio measured in 3D had a good negative correlation with stress after CVO and had more influence on stress distribution in comparison to other geometric parameters. Conclusions For making decisions about the biomechanics of CVO, a CVO angle of > 20° was recommended for type B and > 30° was safe for type C1. The risk of progressive collapse was increased in the insufficient situation of the weight-bearing portion after CVO. The intact ratio could provide information about clinical outcomes and stress distribution after CVO.

Use of antimicrobial photodynamic therapy in the treatment of medication-related osteonecrosis of the jaw

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating complication associated with antiresorptive agents, in which treatment can be quite challenging. This study aimed to report two cases of cancer patients with MRONJ treated in a complementary manner by antimicrobial photodynamic therapy (aPDT). Both patients were male, 84 and 82 years old, respectively, and had a diagnosis of prostate adenocarcinoma and bone metastasis, treated with intravenous injections of bisphosphonates. The dental history for both was toothache, followed by extraction of dental elements that culminated with the appearance of necrotic bone in the mandibular region, which was confirmed with imaging exams and histopathological reports. The treatment protocol for both cases consisted of performing the aPDT once a week, associated with the use of 10 volumes hydrogen peroxide and 0.12% chlorhexidine digluconate for continuous use after oral brushing and amoxicillin with clavulanate three times a day for 7 days. The patient in case 1 performed 27 sessions, responded well to treatment, however, due to complications of the underlying neoplasm, he died without complete resolution of the osteonecrosis. In case 2, 32 sessions were carried out, with a good evolution of the symptoms. The patient is being followed up for 14 months, with no need for surgical intervention to date. Based on the reported cases and the literature survey, it can be concluded that aPDT can be an effective alternative in cases of MRONJ. The patients in the study in question showed success and control of the clinical picture.

Epi-Mucosa Fixation and Autologous Platelet-Rich Fibrin Treatment in Medication-Related Osteonecrosis of the Jaw

Medication-related osteonecrosis of the jaw (MRONJ) frequently affects patients after treatments with bisphosphonates or denosumab, especially with high doses in patients with bone osteoporosis, neoplastic metastases, or possibly anti-angiogenic treatment for cancer. The aim of this article was to show a new treatment planning for stage 2 and stage 3 MRONJ using platelet-rich fibrin (PRF) at the surgical field to enhance healing in association with a new epi-mucosal fixation technique to prevent or treat mandibular fracture. Two cases were treated by epi-mucosa fixation and autologous PRF use for prevention of mandibular fracture risks related to necrotic bone resection or a narrow fracture reduction. Both cases were successfully treated by this new technique of epi-mucosa fixation combined with autologous PRF and achieved good results and good quality of life. Ability to wear prosthesis with good mastication in the absence of side effect such as infection, plate and screw mobilization, pain, and other disabilities or extension of necrosis was reported. After surgical removal of necrotic bone, no infection was detected without any extension of the necrosis.

Bilateral isolated mylohyoid groove fracture progressing as submandibular abscess: an usual fracture pattern of mandible

The mylohyoid ridges or lines are pairs of anatomical bony structures located on the internal or lingual surface of mandible. They are the origin for the mylohyoid muscle. These bony structures are distinct in the mandibular molar region, well protected and gradually become undiscernible towards anterior mandible. Bilateral, isolated fracture of the mylohyoid ridges without concomitant mandibular fracture is rare and, to the best of the authors knowledge, was never previously described. This case report describes an isolated bilateral mylohyoid groove fracture, where one side of a necrotic bone fragment at the fracture site progress to became a nidus of infection, which later caused submandibular space abscess requiring emergency surgical intervention. Diagnosis, possible theory to explain the occurrence of isolated mylohyoid groove fracture and management of these condition are explained in this report.