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Abstract
Purpose:
The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes.
Methods:
10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively.
Results:
Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20°, volar flexion 15°, radial deviation 0°, ulnar deviation 15°.
References
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Fig. 1.
Algorithm of our standardized treatment of NTM infection of the hand and wrist. TB, tuberculosis; NTM, nontuberculous mycobacteria; AFB, acid fast bacillus; ROM, range of motion.
Fig. 2.
Extensive debridement was performed. (A) The medical photograph shows infective tissue around the flexor tendon of the ring finger. (B) The infective tissue was massively removed preserving the A2 pulley. (C) Biopsy material was sent for histology and culture study.
Fig. 3.
A 47-year-old patient with chronic infective arthritis and osteomyelitis combined with tenosynovitis of the finger joint. This patient had taken steroids for a long period because of lupus disease. (A) Preoperative X-rays shows severely destructed finger joint of the middle finger. (B) Postoperative X-ray shows massive removal of infective bone.
Fig. 4.
A 73-years-old patient with chronic infective arthritis and osteomyelitis combined with tenosynovitis of the wrist joint. This patient had taken steroids for a long period because of lupus disease. (A) Preoperative X-rays shows diffuse osteopenia and bony erosion at the wrist joint. (B) Magnetic resonance imaging shows synovial proliferation wrist joint, involvement of the flexor and extensor tendons, and carpal bone erosion. (C) Extensive debridement including synovectomy and Darrach operation was performed. Postoperative X-rays at the final follow-up shows decreased swelling and consolidation of the remaining carpal bones.
Table 1.
Clinical characteristics of ten cases
MRI/US, magnetic resonance imaging/ultrasound; AFB, acid fast bacillus; PCR TB/NTM, polymerase chain reaction tuberculosis/nontuberculous mycobacteria; Rt, right; F., flexor; TS, tenosynovitis; G/N, chronic granulommatous inflammation/necrosis; RFP, Rifampin; EMB, ethambutol; clari, clarithromycin; INH, isoniazid; Lt, left; IA, infective arthritis; OM, osteomyelitis; E., extensor; CIPR, ciprobay; amik, amikacin; levo, levofloxacin; moxi, moxifloxacin; -, negative; +, positive; 0, was not performed.
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