Tibiadefekt- und Infektpseudarthrosen: Behandlungsergebnisse nach Masquelet-Technik

[Reconstruction of posttraumatic deformities and defects]

The reconstruction of posttraumatic defects of bone and soft tissue, as well as residual deformities of the bone is often a lengthy and complicated procedure. Multiple surgical interventions are necessary to reconstruct the affected extremity and restore its functionality. To achieve an optimal result it often takes months or years and requires great patience and compliance of the patient. This treatment should be carried out in centers with the appropriate instrumental and human resources. Since the pathologies are often complex with bony deformities or loss of bone, as well as infections and soft tissue defects, the treatment should be carried out by very experienced surgeons to successfully manage these complex reconstructions. This often requires interdisciplinary cooperation, especially with experienced plastic surgeons. A soft tissue reconstruction for better blood circulation in the exposed bony structures, as well as the bony defects themselves, can be reconstructed at the same time.

Complications associated using the reamer-irrigator -aspirator (RIA) system: a systematic review and meta-analysis

INTRODUCTION

Complications associated with the application of the Reamer-irrigator-Aspirator (RIA) system are described in the literature. However, to date a systematic review and meta-analysis to assess prevalence of complications associated with the use of the RIA system have not been conducted.

MATERIALS AND METHODS

The review is registered with PROSPERO (CRD42021269982). MEDLINE, the Web of Science Core Collection, and Embase were searched from the inception to 10 August 2021. The primary objective was to assess complications and blood loss associated with the use of the RIA system.

RESULTS

Forty-seven studies involving 1834 procedures performed with the RIA system were finally included. A total of 105 complications were reported, with a pooled estimated overall prevalence of 1.7% with a 95% confidence interval (CI) of 0.40 to 3.60, with cortex perforation being the largest reported complication with a total of 34 incidences. A significant subgroup difference was observed (p = 0.02). In subgroup 1 (bone graft harvesting), complication prevalence was 1.4% (95% CI 0.2-3.4); in subgroup 2 (clearance intramedullary canal) it was 0.7% (95% CI 0.00-6.30) and in subgroup 3 (reaming with RIA system prior to nail fixation) 11.9% (95% CI 1.80-26.40). No statistically significant difference for tibia and femur as RIA system application site was observed (CI 0.69-4.19). In studies reporting blood loss, a mean volume of 803.29 ml, a mean drop of hemoglobin of 3.74 g/dl and a necessity of blood transfusion in 9.72% of the patients were observed.

CONCLUSIONS

The systematic review and meta-analysis demonstrate a low overall prevalence rate of complications associated with the RIA system. However, especially the risk of cortical perforation and the frequently reported relevant intraoperative blood loss are complications that should be anticipated in perioperative management and ultimately considered when using the RIA system.

Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

INTRODUCTION

Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes.

MATERIALS AND METHODS

A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation.

PRIMARY OUTCOMES

limb salvage rate and infection eradication.

SECONDARY OUTCOMES

patient functional outcomes and satisfaction.

RESULTS

Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6-600) and 5.4 cm (1-23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were "very satisfied" with the treatment outcome.

CONCLUSION

A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.

The Utility of Supracutaneous Plating in the Staged Management of Compound Distal Femur Fracture: A Case Report

The aim of this report is to draw attention to the use of a vilipend technique ‘supracutaneous plating’ in the management of compound distal femur fractures. Treatment of compound fractures of the distal femur with bone defects and microbial infection remains a challenging task for orthopaedic trauma surgeons. In this case report, we share our experience with the use of the locking distal femoral plate as an external fixator for the staged management of a compound infected distal femur fracture in a 22-year-old male patient. Staged procedures with proper planning give excellent results for infected fractures. Supracutaneous plating can be a viable and patient-friendly alternative in the staged management of compound distal femur fractures instead of the conventional external fixators.

Reconstruction of Septic Tibial Bone Defects With the Masquelet Technique and External Ring Fixation-A Low Healing Rate and High Complication and Revision Rates

OBJECTIVES

To evaluate the results of a series of septic tibial bone defects treated with the Masquelet technique and external ring fixation as a standardized treatment procedure.

DESIGN

Retrospective study.

SETTING

Level one trauma center.

PATIENTS/PARTICIPANTS

All patients 18 years of age or older with septic diaphyseal bone defects of the tibia who underwent induced membrane treatment with ring fixation at our institution between June 1, 2012, and November 31, 2017.

INTERVENTION

Staged management as described by Masquelet using an external ring fixator for definitive fixation.

MAIN OUTCOME MEASUREMENTS

Bony healing at the last follow-up and the time to healing in months. Functional results were assessed according to the scoring system of the Association for the Study and Application of Methods of Ilizarov. The secondary outcome measures were treatment failure and complications.

RESULTS

Thirty-one patients were treated, with a mean follow-up period of 33 months (range, 13-69 months). Overall, among 14 patients assessed as having achieved bone healing, an average of 3.7 surgical revisions were required. The mean healing time was 15.5 months (range, 6-49 months). According to the Association for the Study and Application of Methods of Ilizarov criteria, 7 patients were rated as "excellent" and 6 patients were rated as "good"; one patient showed "poor" functional results. A total of 17 cases of treatment failure and 36 complications were detected.

CONCLUSIONS

The combination of the Masquelet technique and external fixation yielded a low healing rate and was associated with a significant number of cases of treatment failure.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Influence of an Occult Infection on the Outcome of Autologous Bone Grafting During Surgical Bone Reconstruction: A Large Single-Center Case-Control Study

Background

Occult infections (OI) lack typical inflammatory signs, making them challenging to diagnose. Uncertainty remains regarding OI’s influence on the outcome of autologous bone grafting (ABG), and evidence-based recommendations regarding an appropriate course of action are missing. Thus, we sought to determine the incidence of an OI in patients receiving ABG, evaluate whether it influences the outcome of ABG and whether associated risk factors have a further negative influence.

Methods

This study was designed as a large size single-center case-control study investigating patients treated between 01/01/2010 and 31/12/2016 with a minimum follow-up of 12 months. Patients ≥18 years presenting with a recalcitrant non-union of the lower limb receiving surgical bone reconstruction, including bone grafting, were included. A total of 625 patients were recruited, and 509 patients included in the current study. All patients received surgical non-union therapy based on the “diamond concept” including bone reconstruction using ABG. Additionally, multiple tissue samples were harvested and microbiologically analyzed. Tissue samples were microbiologically evaluated regarding an OI. Bone healing was analyzed using clinical and radiological parameters, patient characteristics and comorbidities investigated and ultimately results correlated.

Results

Forty-six out of 509 cases with OI resulted in an incidence of 9.04%. Overall consolidation time was increased by 15.08 weeks and radiological outcome slightly impaired (79.38% vs 71.42%), differences were at a non-significant extent. Diabetes mellitus had a significant negative influence on consolidation time (p=0.0313), while age (p=0.0339), smoking status (p=0.0337), diabetes mellitus (p=0.0400) and increased BMI (p=0.0315) showed a significant negative influence on the outcome of bone grafting.

Conclusion

Surgeons treating recalcitrant non-unions should be aware that an OI is common. If an OI is diagnosed subsequent to ABG the majority of patients does not need immediate revision surgery. However, special attention needs to be paid to high-risk patients.

[The wrapping induced membrane technique for treating recalcitrant non unions]

The induced membrane technique is now well accepted for reconstruction of segmental bone defect. On the other hand, some cases of aseptic non-union are unsuccessfully treated by several surgical attempts for obtaining bone healing. The two stages wrapping induced membrane technique was developed initially for treating atrophic and recalcitrant aseptic non union without bone loss. At the first stage, the site of non-union was firmly fixed and tiles of cement were placed close to the bone on two or three aspects of the bone. At the second stage, after removing the spacers, the induced cavities were filled with cancellous bone autograft. In the two reported cases bone healing was acquired in 4 months. One case was a recalcitrant atrophic non-union of the humeral shaft, the other case concerned the enhancement of an insufficient segmental reconstruction of the femur. The follow up were respectively 3 years and 2 years without complication. The membrane induced by the cement tiles prevents the bone graft resorption and improves the osteogenicity through its biological properties.

Evaluation of the clinical use of the ETN PROtect® in non-union therapy

INTRODUCTION

Non-union of a long bone fracture remains a challenge in orthopaedic and trauma surgery. In the current study, we sought to determine the clinical effectiveness of tibial non-union treatment utilizing an antibiotic-coated intramedullary nail (Expert Tibia Nail (ETN) PROtect®) regarding prevention and treatment of infection and the clinical outcome.

PATIENTS AND METHODS

36 patients suffering from tibial non-unions that were treated with the ETN PROtect® in the course of non-union treatment between February 2010 and March 2015 were included in this clinical observational study. Clinical and radiological examinations were performed preoperatively as well as 4, 6 and 12 weeks and 6 and 12 months postoperatively as part of a standardized follow-up program. Data regarding perioperative complications, weight-bearing capacity, radiological signs of consolidation and subjective health status were assessed at each time point. Laboratory parameters such as C-reactive protein (CRP) and leukocyte count were collected preoperatively in order to assess the patients' risk profile for infection.

RESULTS

Patients had an average of 6.2 previous surgeries and 22 patients (61.1%) had a positive bacterial culture from intraoperatively removed tissue during the first operative treatment. 29 patients (80.6%) achieved full weight-bearing after an average of 7.7 months, furthermore 80.6% of patients achieved osseous consolidation. 3 deep infections occurred, including one amputation. Subjective health status increase based on the SF-12 questionnaire during our follow-up program.

CONCLUSION

The results from the current study indicate that the use of the ETN PROtect® in the applied non-union therapy has a high clinical effectiveness regarding osseous consolidation and time to weight bearing. In addition, the use of gentamicin-coated nails in the treatment of tibial non-unions might contribute to both successful treatment of the underlying infection and prevention of perioperative infection. The gentamicin-coated nail may serve as a beneficial adjunct treatment in the applied non-union therapy in addition to all established techniques in the treatment of infected non-unions.

Evaluation of matrix metalloproteases as early biomarkers for bone regeneration during the applied Masquelet therapy for non-unions

INTRODUCTION

In the current study, we sought to determine if serum concentrations of MMPs correlate with bone regeneration occurring during the course of the Masquelet-therapy and to identify if MMPs may serve as early biomarkers reflecting successful bone regeneration and tissue remodeling.

MATERIAL AND METHODS

This study was designed as a prospective clinical observer study. We compared serum samples over the time of treatment, as a matched-pair analysis, from 10 patients who were treated successfully with the Masquelet-therapy (Responder) with 10 patients who did not respond to the Masquelet-therapy (Non-Responder). The quantitative measurement was performed with Luminex Performance Human High Sensitivity Assays according to manufacturer's instructions. The lab technician performing the Luminex assays was blinded to both patient data and clinical outcome.

RESULTS

Analysis of the expression pattern of MMP-2, -8 and -9 showed significant differences between groups. Two days after the first step of the Masquelet therapy Responder showed peak values of MMP-8 and MMP-9 that where significantly higher (p = 0.003 and p = 0.042, respectively) than in Non-Responder. In contrast serum levels of MMP-2 were lower after the first step of the Masquelet therapy in the Non-Responder group. The ratio of MMP-9 and MMP-2 was significantly higher in the Responder group two days after step I (p = 0.031) as well as 4 weeks after step II (p = 0.030).

CONCLUSION

The findings of the current study emphasize the potential role of MMPs as biomarkers in bone remodeling. In particular, a distinct expression of MMP-2 correlates with successful bone regeneration, whereas initial overexpression of MMP-2 serum levels might identify patients that have a higher risk for a poor outcome of the Masquelet-therapy. Furthermore, we were able to introduce the serum analysis of the ratio of MMP-9 and MMP-2 as promising novel modality for early prediction of the outcome of the Masquelet therapy. Further analysis of this ratio over time subsequent to the second step might serve as an early indicator of a favorable response to the induced membrane technique.

Basic Science and Clinical Application of Reamed Sources for Autogenous Bone Graft Harvest

Autologous bone graft remains the only clinically available source of graft material with osteogenic, osteoinductive, and osteoconductive properties. Although iliac crest autologous bone graft has long served as the benchmark, reamed autogenous bone graft offers several advantages. Reamed autograft has a biochemical and cellular profile that is at least equivalent, and perhaps superior, to that of iliac crest autograft. In addition, larger volumes of reamed autograft can be obtained via less-invasive techniques, giving surgeons an accessible source of mesenchymal stem cells that can be reliably and repeatedly harvested. Early clinical experience involving reamed autogenous bone graft in the management of nonunion, bone defects, and arthrodesis has been encouraging and has demonstrated the necessary properties to warrant regular consideration of reamed graft for these applications.

Segmental Bone Defect Treated With the Induced Membrane Technique

PURPOSE

Posttraumatic bone defects in the setting of severe open injuries of the lower extremity present a significant challenge for orthopaedic trauma surgeons. The induced membrane technique, also known as the Masquelet technique, has been shown to be generally successful in achieving bony union. This video demonstrates the use of the Masquelet technique for a large (18 cm) femoral defect.

METHODS

The Masquelet technique is a 2-stage process. The first stage involves debridement of all devitalized tissue, using open reduction and internal fixation, and placement of a cement spacer with or without antibiotics. In the second stage, which is performed at least 6 weeks after the first, the spacer is removed and the resulting void is filled with bone graft.

RESULTS

This surgical case video reviews the relevant patient injury presentation, initial management, and indications for the Masquelet technique. The second stage of the Masquelet technique is featured in this video.

CONCLUSIONS

The Masquelet technique is a generally reliable method for treating large segmental bone defects. In addition, this relatively simple technique is suitable for both infected and noninfected cases.

Treatment of atrophic femoral non-unions according to the diamond concept: Results of one- and two-step surgical procedure

BACKGROUND

The treatment of non-unions in long bones poses a great challenge, particularly in cases of infection or large osseous defects. This article evaluates the use of the diamond concept in the treatment of femoral non-unions in a one-step or two-step procedure according to the Masquelet technique.

PATIENTS AND METHODS

Between February 2010 and March 2014, 88 patients with atrophic femoral non-unions were included in our study. The treatment was performed in one step (Group G1) on 41 patients and in two-step Masquelet technique (Group G2) on 47 patients, according to the diamond concept. In 72 cases it was decided to apply the growth factor BMP-7. The mean age of patients was 49.9 ± 15.3. The data were analysed after following up all patients for at least 12 months after surgery.

RESULTS

74% of patients achieved consolidation in an average of 9.3 months. Positive bacterial cultures were found in 16 cases (18%). The consolidation rate in G2 was dependent on the non-union localisation and the osteosynthesis method applied. 83% of patients treated by intramedullary reaming achieved consolidation, while this was the case for only 60% of patients with osteosynthesis plates. Smokers in G2 had a larger average osseous defect and a lower consolidation rate. The quality of life as assessed with the SF-12 questionnaire had improved in both groups, with no significant differences between G1 and G2 one year after surgery.

CONCLUSIONS

One-step therapy is a suitable method of treatment for aseptic femoral non-unions with small osseous defects, using BMP-7 and RIA in the case of primarily failed atrophic non-union treatment. The Masquelet technique is an efficient means of eradicating infections in non-unions. In combination with intramedullary nailing, this technique is the method of choice for the treatment of femoral shaft non-unions with large defects.