Postsurgical Pyoderma Gangrenosum Following Carpal Tunnel Release: A Rare Disease Following a Common Surgery

Abstract

Objective: Postsurgical pyoderma gangrenosum is a rare but potentially devastating condition for surgical patients. While pyoderma gangrenosum has 2 subtypes, typical and atypical, each can be further classified by its heralding features. These include ulcerative, pustular, bullous, and vegetative. The presentation can be a result of trauma or, as mentioned before, postsurgical. The plastic and reconstructive surgeon most likely will encounter postsurgical pyoderma gangrenosum in practice, as it has been reported in patient populations frequently seen in plastic surgery clinics. Methods: We present a unique case of idiopathic postsurgical pyoderma gangrenosum in a patient who presented after carpal tunnel release, the most common surgery of the hand and wrist performed in the United States annually. This is believed to be the first ever case reported in the literature of pyoderma gangrenosum following carpal tunnel release. Results: The patient's disease course was complicated by surgical debridement prior to diagnosis. Unfortunately, this condition necessitated mid-forearm amputation. The wound eventually healed with primary closure and appropriate medical therapy. Conclusion: Previous experience with this disease, a high index of suspicion, and general education regarding the disease process and its management could potentially have prevented this outcome. We hope to underscore that it is important to consider a patient's entire history and to have a high index of suspicion in unusual postsurgical wounds in order to adequately diagnose, treat, and manage patients who develop postsurgical pyoderma gangrenosum.

Keywords: carpal tunnel; necrotizing infection; nonhealing wound; postsurgical; pyoderma gangrenosum.

Figure 1

Initial wound prior to first operating room debridement. Significant necrotic tissue is noted at the edge of the wounds with concentric expansion from the centrally located original incision over the carpal tunnel.

Figure 2

Initial presentation of the hand after 2 episodes of debridement at an outside facility. A: Single suture holding soft tissue over the median nerve to prevent desiccation. Note the significant necrotic debris without early appearance of a violaceous rim or frank purulence.

Figure 3

Wound after additional debridement of the enlarged wound. A: The median nerve is now exposed, as the flexor tendons are now devoid of paratenon and are no longer viable soft-tissue coverage. B: Necrosis noted at the musculotendinous junction. Subsequent debridement would result in dehiscence of the muscle and tendon at this level. There is also intradermal purulence visible. C: Appearance of violaceous periwound, which was previously not observed.

Figure 4

Affected arm after transradial mid-forearm amputation. Systemic immunosuppression was initiated prior to this procedure. VAC therapy was initiated and continued until the patient successfully healed this wound without further wounds or complication.