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Shen J, Wei Z, Wang S, Wang X, Lin W, Liu L, Wang G. Treatment of infected bone defects with the induced membrane technique. Bone Joint Res 2023; 12:546-558. [PMID: 37697974 PMCID: PMC10495849 DOI: 10.1302/2046-3758.129.bjr-2022-0439.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
Aims This study aimed to evaluate the effectiveness of the induced membrane technique for treating infected bone defects, and to explore the factors that might affect patient outcomes. Methods A comprehensive search was performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases between 1 January 2000 and 31 October 2021. Studies with a minimum sample size of five patients with infected bone defects treated with the induced membrane technique were included. Factors associated with nonunion, infection recurrence, and additional procedures were identified using logistic regression analysis on individual patient data. Results After the screening, 44 studies were included with 1,079 patients and 1,083 segments of infected bone defects treated with the induced membrane technique. The mean defect size was 6.8 cm (0.5 to 30). After the index second stage procedure, 85% (797/942) of segments achieved union, and 92% (999/1,083) of segments achieved final healing. The multivariate analysis with data from 296 patients suggested that older age was associated with higher nonunion risk. Patients with external fixation in the second stage had a significantly higher risk of developing nonunion, increasing the need for additional procedures. The autografts harvested from the femur reamer-irrigator-aspirator increased nonunion, infection recurrence, and additional procedure rates. Conclusion The induced membrane technique is an effective technique for treating infected bone defects. Internal fixation during the second stage might effectively promote bone healing and reduce additional procedures without increasing infection recurrence. Future studies should standardize individual patient data prospectively to facilitate research on the affected patient outcomes.
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Affiliation(s)
- Jie Shen
- Trauma Medical Centre, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
- Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhiyuan Wei
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Wei Lin
- Department of Gynecology, West China Women’s and Children’s Hospital, Sichuan University, Chengdu, China
| | - Lei Liu
- Department of Orthopaedics, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Guanglin Wang
- Trauma Medical Centre, Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
- Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Masquelet Technique for the Tibia: A Systematic Review and Meta-Analysis of Contemporary Outcomes. J Orthop Trauma 2023; 37:e36-e44. [PMID: 36026545 DOI: 10.1097/bot.0000000000002480] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To systematically review outcomes of the Masquelet "induced membrane" technique (MT) in treatment of tibial segmental bone loss and to assess the impact of defect size on union rate when using this procedure. DATA SOURCES PubMed, EBSCO, Cochrane, and SCOPUS were searched for English language studies from January 1, 2010, through December 31, 2019. STUDY SELECTION Studies describing the MT procedure performed in tibiae of 5 or more adult patients were included. Pseudo-arthrosis, nonhuman, pediatric, technique, nontibial bone defect, and non-English studies were excluded, along with studies with less than 5 patients. Selection adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. DATA EXTRACTION A total of 30 studies with 643 tibiae were included in this meta-analysis. Two reviewers systematically screened titles or abstracts, followed by full texts, to ensure quality, accuracy, and consensus among authors for inclusion or exclusion criteria of the studies. In case of disagreement, articles were read in full to assess their eligibility by the senior author. Study quality was assessed using previously reported criteria. DATA SYNTHESIS Meta-analysis was performed with random-effects models and meta-regression. A meta-analytic estimate of union rate independent of defect size when using the MT in the tibia was 84% (95% CI, 79%-88%). There was no statistically significant association between defect size and union rate ( P = 0.11). CONCLUSIONS The MT is an effective method for the treatment of segmental bone loss in the tibia and can be successful even for large defects. Future work is needed to better understand the patient-specific factors most strongly associated with MT success and complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Functional outcomes and health-related quality of life after reconstruction of segmental bone loss in femur and tibia using the induced membrane technique. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04714-9. [PMID: 36460763 PMCID: PMC10374690 DOI: 10.1007/s00402-022-04714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION The induced membrane technique (IMT), frequently called Masquelet technique, is an operative, two-staged technique for treatment of segmental bone loss. Previous studies mainly focused on radiological outcome parameters and complication rates, while functional outcomes and health-related quality of life after the IMT were sparsely reported. MATERIALS AND METHODS Retrospective study containing of a chart review as well as a clinical and radiological follow-up examination of all patients treated with the IMT at a single institution. The clinical outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the Short-Form-36 (SF-36) and the visual analog scale (VAS) for pain. The radiographic evaluation contained of standard anteroposterior and lateral, as well as hip-knee-ankle (HKA) radiographs. RESULTS Seventeen patients were included in the study. All had suffered high-energy trauma and sustained additional injuries. Ten bone defects were localized in the femur and seven in the tibia. Ten patients underwent additional operative procedures after IMT stage 2, among them three patients who contracted a postoperative deep infection. The median LEFS was 59 (15-80), and the SF-36 physical component summary (PCS) and mental component summary (MCS) were 41.3 (24.0-56.1) and 56.3 (13.5-66.2), respectively. The median length of the bone defect was 9 (3-15) cm. In 11 patients, union was obtained directly after IMT stage 2. Bone resorption was observed in two patients. At follow-up, 16 of the 17 bone defects had healed. The median follow-up was 59 months (13-177). CONCLUSION Our results show a high occurrence of complications after IMT stage 2 in segmental bone defects of femur and tibia requiring additional operative procedures. However, fair functional outcomes as well as a good union rate were observed at follow-up.
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Rigal S. Stratégie de prise en charge des fracas des membres inférieurs en chirurgie de guerre. Réparé ou amputé : le soldat debout. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Masquelet technique in military practice: specificities and future directions for combat-related bone defect reconstruction. Mil Med Res 2022; 9:48. [PMID: 36050805 PMCID: PMC9438145 DOI: 10.1186/s40779-022-00411-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022] Open
Abstract
Because of its simplicity, reliability, and replicability, the Masquelet induced membrane technique (IMT) has become one of the preferred methods for critical bone defect reconstruction in extremities. Although it is now used worldwide, few studies have been published about IMT in military practice. Bone reconstruction is particularly challenging in this context of care due to extensive soft-tissue injury, early wound infection, and even delayed management in austere conditions. Based on our clinical expertise, recent research, and a literature analysis, this narrative review provides an overview of the IMT application to combat-related bone defects. It presents technical specificities and future developments aiming to optimize IMT outcomes, including for the management of massive multi-tissue defects or bone reconstruction performed in the field with limited resources.
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Ren C, Li M, Ma T, Li Z, Xu Y, Sun L, Lu Y, Wang Q, Xue H, Zhang K. A meta-analysis of the Masquelet technique and the Ilizarov bone transport method for the treatment of infected bone defects in the lower extremities. J Orthop Surg (Hong Kong) 2022; 30:10225536221102685. [PMID: 35655431 DOI: 10.1177/10225536221102685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose:To compare the clinical outcomes of the Masquelet technique and Ilizarov bone transport method for the treatment of patients with infected bone defects in the lower extremities. Methods: Eligible studies were searched from six databases until 12 April 2021. Data extraction was independently conducted by two investigators, which was followed by a quality assessment. Weighted mean difference (WMD) and 95% confidence interval (CI) were used to analyze continuous variables, while odds ratio (OR) and 95% CI were used to analyze categorical variables. All statistical analyses were conducted using RevMan 5.3 and Stata 12.0. Results: Thirteen articles were included in this meta-analysis. There was a significant difference observed in hospitalization costs (WMD [95% CI] = -1.75 [-2.50, -0.99] thousand US dollar, p < 0.00,001), final union time (WMD [95% CI] = -4.54 [-6.91, -2.17] months, p = 0.0002), time to full weight bearing (WMD [95% CI] = -1.73 [-3.36, -0.10] months, p = 0.04), quality of life (WMD [95% CI] = 7.70 [4.74, 10.67], p < 0.00,001), and the risk of complications (OR [95%CI] = 0.39 [0.19, 0.79], p = 0.009) between the Masquelet and Ilizarov groups. No significant differences in other outcomes were observed between the two groups. Conclusion: Masquelet technique exhibited the advantages in the lower hospitalization cost, shorter final union time, shorter time to full weight bearing, lower rate of complications, and better post-operative quality of life, compared with Ilizarov bone transport method. However, this finding should be confirmed in large-scale clinical samples.
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Affiliation(s)
- Cheng Ren
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Ming Li
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Teng Ma
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Zhong Li
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Yibo Xu
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Liang Sun
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Yao Lu
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Qian Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hanzhong Xue
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Kun Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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Li S, Li Y, Jiang Z, Hu C, Gao Y, Zhou Q. Efficacy of total flavonoids of Rhizoma drynariae on the blood vessels and the bone graft in the induced membrane. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 99:153995. [PMID: 35278899 DOI: 10.1016/j.phymed.2022.153995] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Total flavonoids of Rhizoma drynariae (TFRD), a Chinese medicine, is widely used in the treatment of orthopedic diseases. However, there are few basic and clinical studies on the effect of TFRD on induced membrane technique (Masquelet technique). PURPOSE This trial is to explore effects of TFRD on vascularization of the induced membrane, and mineralization of the bone graft in rats with femoral bone defects. STUDY DESIGN AND METHODS Forty-eight Sprague-Dawley rats were randomly divided into high dose group (H-TFRD), medium dose group (M-TFRD), low dose group (L-TFRD) and control group (control). The segmental bone defects were established with 12 rats in per group. The polymethyl methacrylate (PMMA) spacer was implanted into the femoral bone defect of rats in the first-stage surgery. About 4 weeks after first-stage surgery, induced membranes of 6 rats in each group were selected. The blood vessels and angiogenesis-related factors in the induced membrane were analyzed by hematoxylin-eosin (HE) and masson staining, western blot, qPCR and immunohistostaining. The remaining rats in per group underwent second-stage surgery (bone grafting). Twelve weeks after the bone grafting, the bone tissues was examined by X-ray, micro-computed tomography (Micro-CT), HE staining and enzyme-linked immunosorbent assay (ELISA) to evaluate the growth of the bone graft. Meanwhile, the TFRD-containing serum was collected from rats to culture osteoblasts in vitro. Cell Counting Kit-8 (CCK-8) method, Alizarin Red S (ARS) staining, western blot and immunofluorescence were used to detect effects of TFRD on the osteoblasts' proliferation and BMP-SMAD signaling pathway. RESULTS Compared with the L-TFRD and control groups, the number of blood vessels and the expression of angiogenesis-related factors (VEGF, TGF-β1, BMP-2, PDGF-BB and CD31) were higher in the H-TFRD and M-TFRD groups. The Lane-Sandhu X-ray score, bone mass and growth rate of the bone graft in the H-TFRD and M-TFRD groups were significantly better than those in the L-TFRD and control groups. In addition, medium and high doses of TFRD significantly increased the expression of BMP-SMAD pathway proteins (BMP-2, SMAD1, SMAD4, SMAD5 and RUNX2) in rat serum and bone graft. In vitro, after osteoblasts were intervened with TFRD-containing serum from the H-TFRD and M-TFRD groups, the cell viability, the number of mineralized nodules and the phosphorylation of BMP-SMAD pathway proteins were markedly increased. CONCLUSION TFRD could promote the formation of blood vessels and the expression of angiogenesis-related factors during the formation of the induced membrane. During the growing period of bone graft, it could facilitate the growth and mineralization of bone graft in a dose-dependent manner, which is partly related to the activation and phosphorylation of BMP-SMAD signaling pathway.
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Affiliation(s)
- Shuyuan Li
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yue Li
- First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zexin Jiang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Cheng Hu
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ya Gao
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qishi Zhou
- First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China.
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VICENTI G, OTTAVIANI G, BIZZOCA D, CARROZZO M, SIMONE F, GROSSO A, ZAVATTINI G, ELIA R, MARUCCIA M, SOLARINO G, MORETTI B. The role of biophysical stimulation with pemfs in fracture healing: from bench to bedside. MINERVA ORTHOPEDICS 2022. [DOI: 10.23736/s2784-8469.21.04116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Littlefield CP, Wang C, Leucht P, Egol KA. The Basic Science Behind the Clinical Success of the Induced Membrane Technique for Critical-Sized Bone Defects. JBJS Rev 2021; 9:01874474-202106000-00010. [PMID: 34125719 DOI: 10.2106/jbjs.rvw.20.00206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The induced membrane technique (IMT) takes advantage of an osteoinductive environment that is created by the placement of a cement spacer into a bone defect. » Most commonly, a polymethylmethacrylate (PMMA) spacer has been used, but spacers made from other materials have emerged and achieved good clinical outcomes. » The IMT has demonstrated good results for long-bone repair; however, more research is required in order to optimize union rates as well as delineate more precise indications and surgical timing.
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Zhang S, Vaida J, Parenti J, Lindsey BA, Xing M, Li B. Programmed Multidrug Delivery Based on Bio-Inspired Capsule-Integrated Nanocoatings for Infected Bone Defect Treatment. ACS APPLIED MATERIALS & INTERFACES 2021; 13:12454-12462. [PMID: 33683872 PMCID: PMC10401608 DOI: 10.1021/acsami.0c20332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Infection and delayed wound healing are two major serious complications related to traumatic injuries and cause a significant burden to patients and society. Most currently available drug delivery materials typically carry a single drug, lack protection from drug loading, and face challenges in on-demand and precisely controlled drug release. Here, we report a flower (Cirsium arvense)-inspired capsule-integrated multilayer nanofilm (FICIF), synthesized using a layer-by-layer self-assembly, for programmed multiple drug co-delivery for trauma (open fracture as an example) treatments. Our approach allows polypeptide multilayer nanofilms and innovative impregnated capsules to assemble hierarchical reservoirs with specific drug binding sites, shielding protection capability, and ordered packing structures. The resultant FICIF nanocarriers enable sustained and on-demand co-delivery of a unique immune-tuning cytokine (interleukin 12p70) and a growth factor (bone morphogenetic protein 2) in clinical use, resulting in extraordinary anti-infection (3 orders of magnitude improved bacterial killing) and bone regeneration (5 times enhanced bone healing) in treating infected rat femur fractures. The successful synthesis of these biomimetic high-performance delivery nanocoatings is expected to serve as a source of inspiration for the development of biomaterials for various clinical applications.
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Affiliation(s)
- Shichao Zhang
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, West Virginia 26506, United States
| | - Justin Vaida
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, West Virginia 26506, United States
| | - Josh Parenti
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, West Virginia 26506, United States
| | - Brock A Lindsey
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, West Virginia 26506, United States
| | - Malcolm Xing
- Department of Mechanical Engineering, University of Manitoba, and the Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba R3E 3P4, Canada
| | - Bingyun Li
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, West Virginia 26506, United States
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Mathieu L, Durand M, Collombet JM, de Rousiers A, de l'Escalopier N, Masquelet AC. Induced membrane technique: a critical literature analysis and proposal for a failure classification scheme. Eur J Trauma Emerg Surg 2020; 47:1373-1380. [PMID: 33226484 DOI: 10.1007/s00068-020-01540-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/31/2020] [Indexed: 02/08/2023]
Abstract
The reconstruction of long-bone segmental defects remains challenging, with the three common methods of treatment being bone transport, vascularized bone transfer, and the induced membrane technique (IMT). Because of its simplicity, replicability, and reliability, usage of IMT has spread all over the world in the last decade, with more than 300 papers published in the PubMed literature database on this subject so far. Most of the clinical studies have reported high rates of bone union, yet some also include more controversial results with frequent complications and revision surgeries. At the same time, various experimental research efforts have been designed to understand and improve the biological properties of the induced membrane. This literature review aims to provide an overview of IMT clinical results in terms of bone union and complications and to compare them with those of other reconstructive procedures. In light of our findings, we then propose an original classification scheme of IMT failures distinguishing between preventable and nonpreventable failures.
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Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Marjorie Durand
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Jean-Marc Collombet
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Arnaud de Rousiers
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Nicolas de l'Escalopier
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Alain-Charles Masquelet
- Department of Orthopedic, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
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Gohel N, Senos R, Goldstein SA, Hankenson KD, Hake ME, Alford AI. Evaluation of global gene expression in regenerate tissues during Masquelet treatment. J Orthop Res 2020; 38:2120-2130. [PMID: 32233004 PMCID: PMC7494657 DOI: 10.1002/jor.24676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/19/2020] [Accepted: 03/25/2020] [Indexed: 02/04/2023]
Abstract
The Masquelet induced-membrane (IM) technique is indicated for large segmental bone defects. Attributes of the IM and local milieu that contribute to graft-to-bone union are unknown. Using a rat model, we compared global gene expression profiles in critically sized femoral osteotomies managed using a cement spacer as per Masquelet to those left empty. At the end of the experiment, IM and bone adjacent to the spacer were collected from the Masquelet side. Nonunion tissue in the defect and bone next to the empty defect were collected from the contralateral side. Tissues were subjected to RNA isolation, sequencing, and differential expression analysis. Cell type enrichment analysis suggested the IM and the bone next to the polymethylmethacrylate (PMMA) spacer were comparatively enriched for osteoblastic genes. The nonunion environment was comparatively enriched for innate and adaptive immune cell markers, but only macrophages were evident in the Masquelet context. iPathwayGuide was utilized to identify cell signaling pathways and protein interaction networks enriched in the Masquelet environment. For IM vs nonunion false-discovery rate correction of P values rendered overall pathway differences nonsignificant, and so only protein interaction networks are presented. For the bone comparison, substantial enrichment of pathways and networks known to contribute to osteogenic mechanisms was revealed. Our results suggest that the PMMA spacer affects the cut bone ends that are in contact with it and at the same time induces the foreign body reaction and formation of the IM. B cells in the empty defect suggest a chronic inflammatory response to a large segmental osteotomy.
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Affiliation(s)
- Nishant Gohel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rafael Senos
- Department of Morphology, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Steven A. Goldstein
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kurt D. Hankenson
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark E. Hake
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Address correspondence to Mark E. Hake: Department of Orthopaedic Surgery, University of Michigan School of Medicine, 1500 E Medical Center Drive, 2912 Taubman Center SPC 5328; Ann Arbor, MI 48109; fax: +1-734-647-3277; telephone: +734-936-9839;
| | - Andrea I. Alford
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Address correspondence to Andrea I. Alford: Department of Orthopaedic Surgery, University of Michigan School of Medicine, A. Alfred Taubman Biomedical Sciences Research Building, Room 2009, Ann Arbor, MI, 48109; fax: +1-734 -647-0003; telephone: +1-734-615-6104;
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Choufani C, Demoures T, de l'Escalopier N, Chapon MP, Barbier O, Mathieu L. Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad. Eur J Trauma Emerg Surg 2020; 48:593-599. [PMID: 32857239 DOI: 10.1007/s00068-020-01471-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/21/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad. METHODS A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application. RESULTS Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage. CONCLUSIONS This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.
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Affiliation(s)
- Camille Choufani
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France.
| | - Thomas Demoures
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France
| | - Nicolas de l'Escalopier
- Clinic of Orthopedics, Traumatology and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France
| | - Marie-Pauline Chapon
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France
| | - Olivier Barbier
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France
- French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75005, Paris, France
| | - Laurent Mathieu
- Clinic of Orthopedics, Traumatology and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France
- French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75005, Paris, France
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Mathieu L, Tossou-Odjo L, de l'Escalopier N, Demoures T, Baus A, Brachet M, Masquelet AC. Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects. INTERNATIONAL ORTHOPAEDICS 2020; 44:1647-1653. [PMID: 32696330 DOI: 10.1007/s00264-020-04735-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/14/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT). METHODS A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2. RESULTS Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence. CONCLUSIONS Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.
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Affiliation(s)
- Laurent Mathieu
- Clinic of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,Department of surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Léon Tossou-Odjo
- Clinic of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Nicolas de l'Escalopier
- Clinic of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Thomas Demoures
- Clinic of Orthopedics and Traumatology, Bégin Military Hospital, 69 avenue de Paris, 94160, Saint-Mandé, France
| | - Arnaud Baus
- Clinic of Esthetic and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Michel Brachet
- Clinic of Esthetic and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Alain Charles Masquelet
- Clinic of Orthopedics, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
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Vidal L, Kampleitner C, Brennan MÁ, Hoornaert A, Layrolle P. Reconstruction of Large Skeletal Defects: Current Clinical Therapeutic Strategies and Future Directions Using 3D Printing. Front Bioeng Biotechnol 2020; 8:61. [PMID: 32117940 PMCID: PMC7029716 DOI: 10.3389/fbioe.2020.00061] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/24/2020] [Indexed: 12/25/2022] Open
Abstract
The healing of bone fractures is a well-orchestrated physiological process involving multiple cell types and signaling molecules interacting at the fracture site to replace and repair bone tissue without scar formation. However, when the lesion is too large, normal healing is compromised. These so-called non-union bone fractures, mostly arising due to trauma, tumor resection or disease, represent a major therapeutic challenge for orthopedic and reconstructive surgeons. In this review, we firstly present the current commonly employed surgical strategies comprising auto-, allo-, and xenograft transplantations, as well as synthetic biomaterials. Further to this, we discuss the multiple factors influencing the effectiveness of the reconstructive therapy. One essential parameter is adequate vascularization that ensures the vitality of the bone grafts thereby supporting the regeneration process, however deficient vascularization presents a frequently encountered problem in current management strategies. To address this challenge, vascularized bone grafts, including free or pedicled fibula flaps, or in situ approaches using the Masquelet induced membrane, or the patient’s body as a bioreactor, comprise feasible alternatives. Finally, we highlight future directions and novel strategies such as 3D printing and bioprinting which could overcome some of the current challenges in the field of bone defect reconstruction, with the benefit of fabricating personalized and vascularized scaffolds.
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Affiliation(s)
- Luciano Vidal
- INSERM, UMR 1238, PHY-OS, Bone Sarcomas and Remodeling of Calcified Tissues, Faculty of Medicine, University of Nantes, Nantes, France
| | - Carina Kampleitner
- Department of Pharmacology and Toxicology, University of Vienna, Vienna, Austria
| | - Meadhbh Á Brennan
- INSERM, UMR 1238, PHY-OS, Bone Sarcomas and Remodeling of Calcified Tissues, Faculty of Medicine, University of Nantes, Nantes, France.,Harvard School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, United States
| | - Alain Hoornaert
- INSERM, UMR 1238, PHY-OS, Bone Sarcomas and Remodeling of Calcified Tissues, Faculty of Medicine, University of Nantes, Nantes, France.,CHU Nantes, Department of Implantology, Faculty of Dental Surgery, University of Nantes, Nantes, France
| | - Pierre Layrolle
- INSERM, UMR 1238, PHY-OS, Bone Sarcomas and Remodeling of Calcified Tissues, Faculty of Medicine, University of Nantes, Nantes, France
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Affiliation(s)
- Meng Mi
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | | | - Xinbao Wu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Verboket RD, Leiblein M, Janko M, Schaible A, Brune JC, Schröder K, Heilani M, Fremdling C, Busche Y, Irrle T, Marzi I, Nau C, Henrich D. From two stages to one: acceleration of the induced membrane (Masquelet) technique using human acellular dermis for the treatment of non-infectious large bone defects. Eur J Trauma Emerg Surg 2020; 46:317-327. [PMID: 31932852 PMCID: PMC7113234 DOI: 10.1007/s00068-019-01296-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/23/2019] [Indexed: 11/24/2022]
Abstract
Introduction The induced membrane technique for the treatment of large bone defects is a two-step procedure. In the first operation, a foreign body membrane is induced around a spacer, then, in the second step, several weeks or months later, the spacer is removed and the Membrane pocket is filled with autologous bone material. Induction of a functional biological membrane might be avoided by initially using a biological membrane. In this study, the effect of a human acellular dermis (hADM, Epiflex, DIZG gGmbH) was evaluated for the treatment of a large (5 mm), plate-stabilised femoral bone defect. Material and Methods In an established rat model, hADM was compared to the two-stage induced membrane technique and a bone defect without membrane cover. Syngeneous spongiosa from donor animals was used for defect filling in all groups. The group size in each case was n = 5, the induction time of the membrane was 3–4 weeks and the healing time after filling of the defect was 8 weeks. Results The ultimate loads were increased to levels comparable with native bone in both membrane groups (hADM: 63.2% ± 29.6% of the reference bone, p < 0.05 vs. no membrane, induced membrane: 52.1% ± 25.8% of the reference bone, p < 0.05 vs. no membrane) and were significantly higher than the control group without membrane (21.5%). The membrane groups were radiologically and histologically almost completely bridged by new bone formation, in contrast to the control Group where no closed osseous bridging could be observed. Conclusion The use of the human acellular dermis leads to equivalent healing results in comparison to the two-stage induced membrane technique. This could lead to a shortened therapy duration of large bone defects.
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Affiliation(s)
- René Danilo Verboket
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany.
| | - Maximilian Leiblein
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Maren Janko
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Alexander Schaible
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Jan Claas Brune
- German Institute for Cell and Tissue Replacement (DIZG gemeinnützige GmbH), Berlin, Germany
| | - Katrin Schröder
- Center of Physiology, Cardiovascular Physiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Myriam Heilani
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Charlotte Fremdling
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Yannic Busche
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Tanja Irrle
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Dirk Henrich
- Department of Trauma-, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
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