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Wang X, Huang Y, Liu D, Zeng T, Wang J, Al Hasan MJ, Liu W, Wang D. The Masquelet induced membrane technique with PRP-FG-nHA/PA66 scaffold can heal a rat large femoral bone defect. BMC Musculoskelet Disord 2024; 25:455. [PMID: 38851675 PMCID: PMC11162015 DOI: 10.1186/s12891-024-07567-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/04/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Masquelet membrane induction technology is one of the treatment strategies for large bone defect (LBD). However, the angiogenesis ability of induced membrane decreases with time and autologous bone grafting is associated with donor site morbidity. This study investigates if the PRP-FG-nHA/PA66 scaffold can be used as a spacer instead of PMMA to improve the angiogenesis ability of induced membrane and reduce the amount of autologous bone graft. METHODS Platelet rich plasma (PRP) was prepared and PRP-FG-nHA/PA66 scaffold was synthesized and observed. The sustained release of VEGFA and porosity of the scaffold were analyzed. We established a femur LBD model in male SD rats. 55 rats were randomly divided into four groups depending on the spacer filled in the defect area. "Defect only" group (n = 10), "PMMA" group (n = 15), "PRP-nHA/PA66" group (n = 15) and "PRP-FG-nHA/PA66" group (n = 15 ). At 6 weeks, the spacers were removed and the defects were grafted. The induced membrane and bone were collected and stained. The bone formation was detected by micro-CT and the callus union was scored on a three point system. RESULTS The PRP-FG-nHA/PA66 scaffold was porosity and could maintain a high concentration of VEGFA after 30 days of preparation. The induced membrane in PRP-FG-nHA/PA66 group was thinner than PMMA, but the vessel density was higher.The weight of autogenous bone grafted in PRP-FG-nHA/PA66 group was significantly smaller than that of PMMA group. In PRP-FG-nHA/PA66 group, the bone defect was morphologically repaired. CONCLUSION The study showed that PRP-FG-nHA/PA66 scaffold can significantly reduce the amount of autologous bone graft, and can achieve similar bone defect repair effect as PMMA. Our findings provide some reference and theoretical support for the treatment of large segmental bone defects in humans.
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Affiliation(s)
- Xiaoyu Wang
- Department of Orthopedic Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China
| | - Yong Huang
- Department of Orthopedic Surgery, the Affiliated Hospital of Qinghai University, Xining, Qinghai, China
| | - Daqian Liu
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Teng Zeng
- Department of Orthopedic Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China
| | - Jingzhe Wang
- Department of Orthopedic Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China
| | - Md Junaed Al Hasan
- Department of Orthopedic Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China
| | - Wei Liu
- Department of Orthopedic Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China
| | - Dawei Wang
- Department of Orthopedic Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China.
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Wang Z, Zou C, Zhan X, Li X, Ghen G, Gao J. Application of double plate fixation combined with Masquelet technique for large segmental bone defects of distal tibia: a retrospective study and literature review. BMC Surg 2024; 24:103. [PMID: 38600472 PMCID: PMC11007926 DOI: 10.1186/s12893-024-02396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND There is no effective consensus on the choice of internal fixation method for the Masquelet technique in the treatment of large segmental bone defects of the distal tibia. Thus, the study aimed to investigate the outcomes of the Masquelet technique combined with double plate fixation in the treatment of large segmental bone defects. METHODS This was a retrospective study involving 21 patients with large segmental bone defects of the distal tibia who were treated between June 2017 and June 2020. The length of bone defect ranged from 6.0 cm to 11 cm (mean, 8.19 cm). In the first stage of treatment, following complete debridement, a cement spacer was placed to induce membrane formation. In the second stage, double plate fixation and autologous cancellous bone grafting were employed for bone reconstruction. Each patient's full weight-bearing time, bone healing time, and Iowa ankle score were recorded, and the occurrence of any complications was noted. RESULTS All patients were followed up for 16 to 26 months (mean, 19.48 months). The group mean full weight-bearing time and bone healing time after bone grafting were 2.41 (± 0.37) months and 6.29 (± 0.66) months, respectively. During the treatment, one patient had a wound infection on the medial side of the leg, so the medial plate was removed. The wound completely healed after debridement without any recurrence. After extraction of iliac bone for grafting, one patient had a severe iliac bone defect, which was managed by filling the gap with a cement spacer. Most patients reported mild pain in the left bone extraction area after surgery. The postoperative Iowa ankle score range was 84-94 (P < 0.05). In this cohort, 15 cases were rated as "excellent", and 6 cases as "good" on the Iowa ankle scoring system. CONCLUSION The Masquelet technique combined with double plate fixation is a safe and effective method for the treatment of large segmental bone defects of the distal tibia.
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Affiliation(s)
- Zhaohui Wang
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Chengyou Zou
- The Eighth Affiliated Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaohuan Zhan
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Xianhui Li
- The Eighth Affiliated Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guocai Ghen
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Junqing Gao
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China.
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Konda SR, Boadi BI, Leucht P, Ganta A, Egol KA. Surgical repair of large segmental bone loss with the induced membrane technique: patient reported outcomes are comparable to nonunions without bone loss. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:243-249. [PMID: 37439888 DOI: 10.1007/s00590-023-03580-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/10/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To compare the outcomes of patients with segmental bone loss who underwent repair with the induced membrane technique (IMT) with a matched cohort of nonunion fractures without bone loss. DESIGN Retrospective analysis on prospectively collected data. SETTING Academic medical center. PATIENTS Two cohorts of patients, those with upper and lower extremity diaphyseal large segmental bone loss and those with ununited fractures, were enrolled prospectively between 2013 and 2020. Sixteen patients who underwent repair of 17 extremities with segmental diaphyseal or meta-diaphyseal bone defects treated with the induced membrane technique were identified, and matched with 17 patients who were treated for 17 fracture nonunions treated without an induced membrane. Sixteen of the bone defects treated with the induced membrane technique were due to acute bone loss, and the other was a chronic aseptic nonunion. MAIN OUTCOME MEASUREMENTS Healing rate, time to union, functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA) and pain assessed by the Visual Analog Scale (VAS). RESULTS The initial average defect size for patients treated with the induced membrane technique was 8.85 cm. Mean follow-up times were similar with 17.06 ± 10.13 months for patients treated with the IMT, and 20.35 ± 16.68. months for patients treated without the technique. Complete union was achieved in 15/17 (88.2%) of segmental bone loss cases treated with the IMT and 17/17 (100%) of cases repaired without the technique at the latest follow up visit. The average time to union for patients treated with the induced membrane technique was 13.0 ± 8.4 months and 9.64 ± 4.7 months for the matched cohort. There were no significant differences in reported outcomes measured by the SMFA or VAS. Patients treated with the induced membrane technique required more revision surgeries than those not treated with an induced membrane. CONCLUSION Outcomes following treatment of acute bone loss from the diaphysis of long bones with the induced membrane technique produces clinical and radiographic outcomes similar to those of long bone fracture nonunions without bone loss that go on to heal. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E 17Th St, Suite 1402, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA.
| | - Blake I Boadi
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E 17Th St, Suite 1402, New York, NY, 10003, USA
| | - Philipp Leucht
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E 17Th St, Suite 1402, New York, NY, 10003, USA
| | - Abhishek Ganta
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E 17Th St, Suite 1402, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E 17Th St, Suite 1402, New York, NY, 10003, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
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Uppstu P, Engblom S, Inkinen S, Hupa L, Wilén CE. Influence of polylactide coating stereochemistry on mechanical and in vitro degradation properties of porous bioactive glass scaffolds for bone regeneration. J Biomed Mater Res B Appl Biomater 2024; 112:e35328. [PMID: 37737070 DOI: 10.1002/jbm.b.35328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
The mechanical properties of polylactide stereocomplexes (PLA SC) have been primarily studied through tensile testing, with inconsistent results, and the compressive properties of PLA SC compared to homocrystalline or amorphous PLA remain poorly understood. In this study, we coated porous bioactive glass 13-93 scaffolds with amorphous, homocrystalline, or stereocomplex PLA to investigate their mechanical and degradation properties before and after immersion in simulated body fluid. The glass scaffolds had interconnected pores and an average porosity of 76%. The PLA coatings, which were 10-100 μm thick and approximately 3% of the glass scaffold mass, covered the glass to a large extent. The compressive strength and toughness of all PLA-coated scaffolds were significantly higher than those of uncoated scaffolds, with approximately a fourfold increase before immersion and a twofold increase after immersion. The compressive strength and toughness of PLA SC-coated scaffolds were similar to those of scaffolds with homocrystalline PLA coating, and significantly higher than for scaffolds with amorphous PLA coating. All PLA coatings moderated the initial pH increase caused by the glass, which could benefit surrounding cells and bone tissue in vivo after implantation.
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Affiliation(s)
- Peter Uppstu
- Laboratory of Molecular Science and Technology, Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland
| | - Simon Engblom
- Laboratory of Molecular Science and Technology, Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland
| | - Saara Inkinen
- Laboratory of Molecular Science and Technology, Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland
- Nordic Catalyst e.U., Vienna, Austria
| | - Leena Hupa
- Laboratory of Molecular Science and Technology, Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland
| | - Carl-Eric Wilén
- Laboratory of Molecular Science and Technology, Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland
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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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6
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Liu XL, Zhang CJ, Shi JJ, Ke QF, Ge YW, Zhu ZA, Guo YP. Nacre-mimetic cerium-doped nano-hydroxyapatite/chitosan layered composite scaffolds regulate bone regeneration via OPG/RANKL signaling pathway. J Nanobiotechnology 2023; 21:259. [PMID: 37550715 PMCID: PMC10408205 DOI: 10.1186/s12951-023-01988-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/07/2023] [Indexed: 08/09/2023] Open
Abstract
Autogenous bone grafting has long been considered the gold standard for treating critical bone defects. However, its use is plagued by numerous drawbacks, such as limited supply, donor site morbidity, and restricted use for giant-sized defects. For this reason, there is an increasing need for effective bone substitutes to treat these defects. Mollusk nacre is a natural structure with outstanding mechanical property due to its notable "brick-and-mortar" architecture. Inspired by the nacre architecture, our team designed and fabricated a nacre-mimetic cerium-doped layered nano-hydroxyapatite/chitosan layered composite scaffold (CeHA/CS). Hydroxyapatite can provide a certain strength to the material like a brick. And as a polymer material, chitosan can slow down the force when the material is impacted, like an adhesive. As seen in natural nacre, the combination of these inorganic and organic components results in remarkable tensile strength and fracture toughness. Cerium ions have been demonstrated exceptional anti-osteoclastogenesis capabilities. Our scaffold featured a distinct layered HA/CS composite structure with intervals ranging from 50 to 200 μm, which provided a conducive environment for human bone marrow mesenchymal stem cell (hBMSC) adhesion and proliferation, allowing for in situ growth of newly formed bone tissue. In vitro, Western-blot and qPCR analyses showed that the CeHA/CS layered composite scaffolds significantly promoted the osteogenic process by upregulating the expressions of osteogenic-related genes such as RUNX2, OCN, and COL1, while inhibiting osteoclast differentiation, as indicated by reduced TRAP-positive osteoclasts and decreased bone resorption. In vivo, calvarial defects in rats demonstrated that the layered CeHA/CS scaffolds significantly accelerated bone regeneration at the defect site, and immunofluorescence indicated a lowered RANKL/OPG ratio. Overall, our results demonstrate that CeHA/CS scaffolds offer a promising platform for bone regeneration in critical defect management, as they promote osteogenesis and inhibit osteoclast activation.
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Affiliation(s)
- Xiao-Liang Liu
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Chuan-Jian Zhang
- The Education Ministry Key Lab of Resource Chemistry, Shanghai Key Laboratory of Rare Earth Functional Materials, Shanghai Normal University, Shanghai, 200234, China
| | - Jing-Jing Shi
- The Education Ministry Key Lab of Resource Chemistry, Shanghai Key Laboratory of Rare Earth Functional Materials, Shanghai Normal University, Shanghai, 200234, China
| | - Qin-Fei Ke
- The Education Ministry Key Lab of Resource Chemistry, Shanghai Key Laboratory of Rare Earth Functional Materials, Shanghai Normal University, Shanghai, 200234, China
| | - Yu-Wei Ge
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Shanghai Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Zhen-An Zhu
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Ya-Ping Guo
- The Education Ministry Key Lab of Resource Chemistry, Shanghai Key Laboratory of Rare Earth Functional Materials, Shanghai Normal University, Shanghai, 200234, China.
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Klein C, Gindraux F, Masquelet AC, Mentaverri R, Gouron R. Questions about Using the Induced Membrane Technique to Manage Cases of Congenital Tibial Pseudarthrosis. Cells 2023; 12:1918. [PMID: 37508581 PMCID: PMC10378057 DOI: 10.3390/cells12141918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
The induced membrane technique is an innovative approach for repairing critical bone defects and has been applied recently in patients with congenital pseudarthrosis of the tibia (CPT). CPT is frequently associated with neurofibromatosis type 1 (NF1). Here, we briefly describe the clinical results of the induced membrane technique in NF1-deficient patients with CPT and in an animal model of CPT. Furthermore, we discuss the hypotheses used to explain inconsistent outcomes for the induced membrane technique in CPT-especially when associated with NF1.
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Affiliation(s)
- Céline Klein
- Department of Paediatric Orthopaedic Surgery, Amiens University Hospital, Jules Verne University of Picardie, F-80054 Amiens, France
- MP3CV-EA7517, CURS-Amiens University Medical Center, Jules Verne University of Picardie, F-80025 Amiens, France
- Service D'orthopédie et Traumatologie Pédiatrique, CHU Amiens-Picardie, F-80054 Amiens CEDEX 1, France
| | - Florelle Gindraux
- CHU Besançon, Service de Chirurgie Orthopédique, Traumatologique et Plastique, F-25000 Besançon, France
- Laboratoire de Nanomédecine, Imagerie, Université de Franche-Comté, Thérapeutique EA 4662 (LNIT), F-25000 Besançon, France
| | | | - Romuald Mentaverri
- MP3CV-EA7517, CURS-Amiens University Medical Center, Jules Verne University of Picardie, F-80025 Amiens, France
- CHU Besançon, Service de Chirurgie Orthopédique, Traumatologique et Plastique, F-25000 Besançon, France
- Laboratoire de Nanomédecine, Imagerie, Université de Franche-Comté, Thérapeutique EA 4662 (LNIT), F-25000 Besançon, France
- Hôpital Saint Antoine, Sorbonne Université, F-75006 Paris, France
- Department of Biochemistry and Endocrine Biology, Amiens University Medical Center, Jules Verne University of Picardie, F-80025 Amiens, France
| | - Richard Gouron
- Department of Paediatric Orthopaedic Surgery, Amiens University Hospital, Jules Verne University of Picardie, F-80054 Amiens, France
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Ahmed H, Shakshak M, Trompeter A. A review of the Masquelet technique in the treatment of lower limb critical-size bone defects. Ann R Coll Surg Engl 2023. [PMID: 37367227 DOI: 10.1308/rcsann.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
The need for bone tissue to heal effectively is paramount given its role in the mechanical support of tissues. Bone has a very good natural healing potential in comparison with most other tissue types, largely regenerating to its pre-injury state in the vast majority of cases. Certain factors such as high energy trauma, tumour resection, revision surgery, developmental deformities and infection can lead to the formation of bone defects, where the intrinsic healing potential of bone is diminished owing to bone loss. Various approaches to resolving bone defects exist in current practice, each with their respective benefits and drawbacks. These include bone grafting, free tissue transfer, Ilizarov bone transport and the Masquelet induced membrane technique. This review focuses on evaluating the Masquelet technique, discussing its method and underlying mechanisms, the effectiveness of certain modifications, and its potential future directions.
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Affiliation(s)
- H Ahmed
- St George's, University of London, UK
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Huang F, Liu X, Fu X, Chen Y, Jiang D, Wang T, Hu R, Zou X, Hu H, Liu C. 3D-Printed Bioactive Scaffold Loaded with GW9508 Promotes Critical-Size Bone Defect Repair by Regulating Intracellular Metabolism. Bioengineering (Basel) 2023; 10:bioengineering10050535. [PMID: 37237605 DOI: 10.3390/bioengineering10050535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/14/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
The process of bone regeneration is complicated, and it is still a major clinical challenge to regenerate critical-size bone defects caused by severe trauma, infection, and tumor resection. Intracellular metabolism has been found to play an important role in the cell fate decision of skeletal progenitor cells. GW9508, a potent agonist of the free fatty acid receptors GPR40 and GPR120, appears to have a dual effect of inhibiting osteoclastogenesis and promoting osteogenesis by regulating intracellular metabolism. Hence, in this study, GW9508 was loaded on a scaffold based on biomimetic construction principles to facilitate the bone regeneration process. Through 3D printing and ion crosslinking, hybrid inorganic-organic implantation scaffolds were obtained after integrating 3D-printed β-TCP/CaSiO3 scaffolds with a Col/Alg/HA hydrogel. The 3D-printed β-TCP/CaSiO3 scaffolds had an interconnected porous structure that simulated the porous structure and mineral microenvironment of bone, and the hydrogel network shared similar physicochemical properties with the extracellular matrix. The final osteogenic complex was obtained after GW9508 was loaded into the hybrid inorganic-organic scaffold. To investigate the biological effects of the obtained osteogenic complex, in vitro studies and a rat cranial critical-size bone defect model were utilized. Metabolomics analysis was conducted to explore the preliminary mechanism. The results showed that 50 μM GW9508 facilitated osteogenic differentiation by upregulating osteogenic genes, including Alp, Runx2, Osterix, and Spp1 in vitro. The GW9508-loaded osteogenic complex enhanced osteogenic protein secretion and facilitated new bone formation in vivo. Finally, the results from metabolomics analysis suggested that GW9508 promoted stem cell differentiation and bone formation through multiple intracellular metabolism pathways, including purine and pyrimidine metabolism, amino acid metabolism, glutathione metabolism, and taurine and hypotaurine metabolism. This study provides a new approach to address the challenge of critical-size bone defects.
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Affiliation(s)
- Fangli Huang
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xiao Liu
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xihong Fu
- Precision Medicine Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yan Chen
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Dong Jiang
- Precision Medicine Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Tingxuan Wang
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Rongcheng Hu
- Precision Medicine Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Xuenong Zou
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Hao Hu
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Chun Liu
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Department of Spinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Precision Medicine Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
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Mittal R, Jain S. Modified Masquelet technique in children. Chin J Traumatol 2022; 25:389-391. [PMID: 34580002 PMCID: PMC9751581 DOI: 10.1016/j.cjtee.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 07/21/2021] [Accepted: 08/20/2021] [Indexed: 02/04/2023] Open
Abstract
Masquelet technique is one of the modalities for the treatment of long bone defect. Using cancellous bone graft to fill the bone defect is always a concern in children due to the small size of their iliac crest and open growth plate. We reported a case of 13-year-old male who presented with gap non-union of middle third of tibia. We applied a modified Masquelet technique by using only the cortical fibular graft instead of cancellous bone to fill the space surrounded by induced membrane. Fibula was used as a nonvascularized strut graft and matched stick graft to achieve complete union. We concluded that nonvascularized fibula grafting is an easy and effective option to fill the bone defect in children in the second stage of Masquelet technique.
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Du T, Zhao S, Dong W, Ma W, Zhou X, Wang Y, Zhang M. Surface Modification of Carbon Fiber-Reinforced Polyetheretherketone with MXene Nanosheets for Enhanced Photothermal Antibacterial Activity and Osteogenicity. ACS Biomater Sci Eng 2022; 8:2375-2389. [PMID: 35652599 DOI: 10.1021/acsbiomaterials.2c00095] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ideal bone implant materials need to provide multiple functions such as biocompatibility, non-cytotoxicity, and bone tissue regeneration guidance. To tackle this challenge, according to our previous work, carbon fiber (40 mm)-reinforced polyetheretherketone (CFPEEK) composites were developed by using 3D needle-punched CFPEEK preform molding technology. Because of the excellent mechanical properties, the CFPEEK needled felt matrix composites have a broad application prospect in orthopedic internal fixation and implant materials. In order to expand the application range of composite materials, it is very necessary to improve the surface bioactivity of composite materials. The surface modification of CFPEEK with 2D titanium carbide (MXene) nanosheets (sulfonated CFPEEK (SCFPEEK)-polydopamine (PDA)-Ti3C2Tx) for enhanced photothermal antibacterial activity and osteogenicity was explored in this study. Here, the new composites we constructed are composed of Ti3C2Tx nanosheets, PDA, and biologically inert SCFPEEK, which gave the bio-inert composites bimodal therapeutic features: photothermal antibacterial activity and in vivo osseointegration. To our knowledge, this is the first time that a CFPEEK implant with a bioactive surface modified by Ti3C2Tx nanosheets was demonstrated. Due to the synergistic photothermal therapy (PTT) treatment of Ti3C2Tx/PDA, SCFPEEK-PDA-Ti3C2Tx (SCP-PDA-Ti) absorbed heat and the temperature increased to 40.8-59.6 °C─the high temperature led to bacterial apoptosis. The SCP-PDA-Ti materials could effectively kill bacteria after 10 min of near-infrared (NIR) irradiation at 808 nm. SCP-PDA-Ti (2.5) and SCP-PDA-Ti (3.0) achieved a 100% bacteriostasis rate. More importantly, the multifunctional implant SCP-PDA-Ti shows good cytocompatibility and an excellent ability to promote bone formation in terms of cytotoxicity, diffusion, alkaline phosphatase activity, alizarin red activity, real-time polymerase chain reaction analysis, and in vivo bone defect osteogenesis experiments. This provides a more extendable development idea for the application of carbon fiber-reinforced composites as orthopedic implants.
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Affiliation(s)
- Tianhui Du
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Shanshan Zhao
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Wenying Dong
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Wendi Ma
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Xingyu Zhou
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Yilong Wang
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Mei Zhang
- Key Laboratory of High Performance Plastics, Ministry of Education, College of Chemistry, Jilin University, Changchun 130012, P. R. China
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Sun H, Godbout C, Ryan G, Hoit G, Higgins J, Schemitsch EH, Nauth A. The induced membrane technique: Optimization of bone grafting in a rat model of segmental bone defect. Injury 2022; 53:1848-1853. [PMID: 35341595 DOI: 10.1016/j.injury.2022.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The induced membrane technique (IMT) is a two-stage surgical procedure used to treat fracture nonunion and bone defects. Although there is an increasing number of animal studies investigating the IMT, few have examined the outcomes of bone healing after a second stage grafting procedure. This study aimed at comparing two bone grafting procedures, as part of the IMT, in order to establish a rat model providing consistent healing outcomes. METHODS In male Fischer 344 rats, we created a 5 mm defect in the right femur, stabilized the bone with a plate and screws, and inserted a polymethylmethacrylate spacer into the defect. Four weeks later, the spacer was removed. Bone graft was harvested from a donor rat and placed into the defect, followed by membrane and wound closure. Experiments were conducted in two groups. In group 1 (n = 11), the bone graft contained a variable amount of cortical and cancellous bone, the time from donor euthanasia to grafting was up to 240 min, and one donor rat provided graft for 5-6 recipients. In group 2 (n = 12), we reduced the contribution of cortical bone to the graft, included bone marrow, and kept donor euthanasia to grafting time under 150 min. One donor was used per 3-4 recipients. The volume of graft per recipient and all other elements of the protocol were the same across groups. Bone healing at 12 weeks post grafting was compared radiographically by two orthopaedic surgeons in a blinded fashion, based on union status and a modified Lane & Sandhu score. RESULTS Healing rates improved from 36.4% in Group 1 to 91.6% in Group 2. There was a significant relationship between the methods and resulting union status (p = 0.004). The odds of achieving full union were significantly higher in group 2 compared to group 1 (odds ratio=19.25, 95% confidence interval [1.77-209.55]; p = 0.009). The average radiographic score was also significantly higher in group 2 (p = 0.005). CONCLUSION The revised bone grafting method significantly improved the healing outcomes and contributed to establishing a consistent rat model of the IMT. This model can benefit preclinical investigations by allowing for reliable and clinically-relevant comparisons.
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Affiliation(s)
- Hening Sun
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Charles Godbout
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada
| | - Gareth Ryan
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Graeme Hoit
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - James Higgins
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Aaron Nauth
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
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Effects of PMMA spacer loaded with varying vancomycin concentrations on bone regeneration in the Masquelet technique. Sci Rep 2022; 12:4255. [PMID: 35277575 PMCID: PMC8917238 DOI: 10.1038/s41598-022-08381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/07/2022] [Indexed: 12/04/2022] Open
Abstract
Whether antibiotics should be included remains greatly debated in Masquelet technique. This study intended to determine the effect of polymethyl methacrylate (PMMA) spacer loaded with different vancomycin concentrations on bone defect repair. Hollow cylindrical spacers consisting of PMMA and varying vancomycin concentrations (0, 1, 2, 4, 6, 8, and 10 g) were prepared. Critical bone defects of rabbits were created at the radial shaft, and spacers were implanted and subsequently intramedullary fixed with retrograde Kirschner’s wires (n = 4 for each vancomycin concentration). After 4 weeks, the induced membranes were opened and cancellous allografts were implanted into the defects. Eight weeks post-operatively, the results of X-ray, histology, and micro-CT revealed that some cortical bone was formed to bridge the gap and the bone marrow cavity was formed over time. Quantitatively, there was more new bone formation in the groups with a relatively lower vancomycin concentration (1–4 g) compared with that in the groups with a higher vancomycin concentration (6–10 g). Our findings suggested that PMMA spacers loaded with relatively lower vancomycin concentrations (1–4 g) did not interfere with new bone formation, whereas spacers loaded with relatively higher vancomycin concentrations (6–10 g) had negative effects on bone formation.
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Pesciallo CA, Garabano G, Dainotto T, Ernst G. Masquelet technique in post-traumatic infected femoral and tibial segmental bone defects. Union and reoperation rates with high proportions (up to 64%) of allograft in the second stage. Injury 2021; 52:3471-3477. [PMID: 34521541 DOI: 10.1016/j.injury.2021.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/18/2021] [Accepted: 08/30/2021] [Indexed: 02/02/2023]
Abstract
Introduction The aim of this study was to describe union, reoperation and failure rates after using the induced membrane (IM) technique with ≥50% allograft over autograft to treat infected femoral and tibial segmental bone defects (SBD). Materials and methods We retrospectively analyzed patients with femoral and tibial SBD treated in our center between 2012 and 2019 using ≥50% allograft over autograft during the second stage of the Masquelet technique. We analyzed the affected bone, defect size, osteosynthesis technique used, time elapsed between the first and second stage of the technique, graft proportions, union time, reoperations, and non-union rates. Results We included 21 patients (61.90% men) with a median age of 41 (range 18-68) years. The tibia was affected in 61.90% (n:13) and the femur in 38.09% (n:8) of the cases. SBD length was 4.5 (range 3.5-14) cm. The median interval between both stages of the technique was 10 (range 6-28) weeks. The proportion of allograft used was 50 % in 10 patients, 51 to 55% in 5 patients, 56 to 59% in 4 patients, and 60 to 64% in 2. The union rate was 95.23% over a median time of 7 (range 6-12) months. There were 3 (14.28%) reoperations: 2 for relapse of infection and 1 for mechanical instability. There was one failure (4.76%). One patient presented non-union and nail break. The median follow-up after the second stage of the technique was 26 (range 13-54) months. Conclusion The use of the induced membrane technique and a high proportion of allograft (up to 64%) achieved similar union and failure rates than those reported for similar series that relied on lower allograft proportions.
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Affiliation(s)
- Cesar Angel Pesciallo
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires Argentina
| | - Germán Garabano
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires Argentina.
| | - Tamara Dainotto
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires Argentina
| | - Glenda Ernst
- Scientific Advisory Committee, British Hospital of Buenos Aires, Buenos Aires Argentina
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Pouwels S, De Jongh F, Willems WF, Nguyen T, Rhemrev SJ. Complications in the Treatment of Delayed Union and Underlying Chronic Osteomyelitis After Right Crural Fracture Treated With Anterolateral Thigh Flap and Double-Barrelled Vascularized Fibula Graft. Cureus 2021; 13:e17923. [PMID: 34660115 PMCID: PMC8513725 DOI: 10.7759/cureus.17923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Segmental bone defects pose a major, unsolved clinical challenge and may be the result of high-energy trauma, infection, and tumour resection or revision surgery. Several options exist to reconstruct, including Ilizarov bone transport, Masquelet technique, cylindrical mesh technique, allografts, and vascularized bone autografts. We present a patient with a delayed union of the tibia with concomitant chronic osteomyelitis treated with anterolateral thigh (ALT) flap and double-barrelled vascularized fibula graft. Case presentation:A 60-year-old male with a chronic pretibial wound with underlying osteomyelitis of the right leg presented himself at the emergency department and was admitted to the surgical ward. He had complex chronic osteomyelitis of a tibial non-union after an earlier right crural fracture (a previous work-related accident). He was treated with an ALT flap and double-barrelled vascularized fibula graft, which was complicated with an additional fracture and breakage of osteosynthesis material. Conclusion: Segmental bone defects pose a major, unsolved clinical challenge in orthopaedic, trauma-surgical, and plastic surgical practice. Concomitant infections and fractures can be part of the postoperative course. Patients with complex segmental bone defects need to be treated by a multidisciplinary team including at least an (orthopaedic) trauma surgeon, a plastic surgeon, and an infectiologist.
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Affiliation(s)
- Sjaak Pouwels
- Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, NLD
| | - Frank De Jongh
- Plastic Surgery, Haaglanden Medical Centre, The Hague, NLD
| | | | - Thuan Nguyen
- Plastic Surgery, Haaglanden Medical Centre, The Hague, NLD
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Xiao H, Wang S, Wang F, Dong S, Shen J, Xie Z. Locking Compression Plate as an External Fixator for the Treatment of Tibia Infected Bone Defects. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021. [PMID: 34496424 DOI: 10.1055/a-1545-5363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE This study was designed to observe the medium-term efficacy of an induced membrane technique combined with a locking compression plate as an external fixator for the treatment of tibia infected bone defects. METHODS Patients with a tibial infection were admitted to our department between January 2013 and November 2014. All patients were treated with the induced membrane technique. In the first stage, polymethyl methacrylate (PMMA) cement was implanted in the defects after debridement and then fixed with a locking compression plate (LCP) as an external fixator. In the second stage, bone grafts were implanted to rebuild the defects. The external plates were replaced with nails in 57 patients (internal group), and the remaining 30 patients were not exchanged with fixation (external group). The infection control rate, bone union rate, and complications of the two groups were compared. RESULTS Eighty-seven patients were enrolled in this study, and all patients had a minimum follow-up of 5 years (average 62.8 months) after grafting. Eighty-three patients (95.4%) achieved bone union, and the average union time was 6.77 months. Five patients (5.7%) experienced recurrence of infection. Complications included pin tract infection, fixation loosening, deformity connection, and limitation of joint range of motion (ROM). No significant differences in the infection control rate or bone defect union rate were noted between the two groups. The overall rate of complications in the external group was 50%, which was greater than that noted in the internal group (21.1%). CONCLUSIONS Locking compression plates are external fixators with smaller sizes that are easier to operate than conventional annular fixators or assembled external fixators. The use of locking compression plates in combination with the induced membrane technique in the treatment of tibia infected bone defects can achieve good clinical efficacy after medium-term follow-up.
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Affiliation(s)
- Hong Xiao
- Department of Orthopaedics, No. 958 Hospital of Army, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shulin Wang
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Feibo Wang
- Department of Orthopaedics, No. 958 Hospital of Army, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Sun Dong
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Shen
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhao Xie
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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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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Eriksson E, Björkenheim R, Strömberg G, Ainola M, Uppstu P, Aalto-Setälä L, Leino VM, Hupa L, Pajarinen J, Lindfors N. S53P4 bioactive glass scaffolds induce BMP expression and integrative bone formation in a critical-sized diaphysis defect treated with a single-staged induced membrane technique. Acta Biomater 2021; 126:463-476. [PMID: 33774197 DOI: 10.1016/j.actbio.2021.03.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/25/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023]
Abstract
Critical-sized diaphysis defects are complicated by inherent sub-optimal healing conditions. The two-staged induced membrane technique has been used to treat these challenging defects since the 1980's. It involves temporary implantation of a membrane-inducing spacer and subsequent bone graft defect filling. A single-staged, graft-independent technique would reduce both socio-economic costs and patient morbidity. Our aim was to enable such single-staged approach through development of a strong bioactive glass scaffold that could replace both the spacer and the graft filling. We constructed amorphous porous scaffolds of the clinically used bioactive glass S53P4 and evaluated them in vivo using a critical-sized defect model in the weight-bearing femur diaphysis of New Zealand White rabbits. S53P4 scaffolds and standard polymethylmethacrylate spacers were implanted for 2, 4, and 8 weeks. Induced membranes were confirmed histologically, and their osteostimulative activity was evaluated through RT-qPCR of bone morphogenic protein 2, 4, and 7 (BMPs). Bone formation and osseointegration were examined using histology, scanning electron microscopy, energy-dispersive X-ray analysis, and micro-computed tomography imaging. Scaffold integration, defect union and osteosynthesis were assessed manually and with X-ray projections. We demonstrated that S53P4 scaffolds induce osteostimulative membranes and produce osseointegrative new bone formation throughout the scaffolds. We also demonstrated successful stable scaffold integration with early defect union at 8 weeks postoperative in critical-sized segmental diaphyseal defects with implanted sintered amorphous S53P4 scaffolds. This study presents important considerations for future research and the potential of the S53P4 bioactive glass as a bone substitute in large diaphyseal defects. STATEMENT OF SIGNIFICANCE: Surgical management of critical-sized diaphyseal defects involves multiple challenges, and up to 10% result in delayed or non-union. The two-staged induced membrane technique is successfully used to treat these defects, but it is limited by the need of several procedures and bone graft. Repeated procedures increase costs and morbidity, while grafts are subject to donor-site complications and scarce availability. To transform this two-staged technique into one graft-independent procedure, we developed amorphous porous scaffolds sintered from the clinically used bioactive glass S53P4. This work constitutes the first evaluation of such scaffolds in vivo in a critical-sized diaphyseal defect in the weight-bearing rabbit femur. We provide important knowledge and prospects for future development of sintered S53P4 scaffolds as a bone substitute.
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Zhang H, Li X, Li J, Zhong L, Chen X, Chen S. SDF-1 mediates mesenchymal stem cell recruitment and migration via the SDF-1/CXCR4 axis in bone defect. J Bone Miner Metab 2021; 39:126-138. [PMID: 33079278 DOI: 10.1007/s00774-020-01122-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/27/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Recent studies have indicated the potential of stem cell therapy in combination with cytokines to restore the bone repair via migration and homing of stem cells to the defected area. The present study aimed to investigate the mobilization and recruitment of mesenchymal stem cells (MSCs) in response to SDF-1. MATERIALS AND METHODS Herein, the knockout rat model of the bone defect (BD) was treated with the induced membrane technique. Then, wild type Wistar rats and SDF-1-knockout rats were selected for the establishment of BD-induced membrane (BD-IM) models and bone-graft (BG) models. The number of MSCs was evaluated by flow cytometry, along with the expression pattern of the SDF-1/CXCR4 axis as well as osteogenic factors was identified by RT-qPCR and Western blot analyses. Finally, the MSC migration ability was assessed by the Transwell assay. RESULTS Our data illustrated that in the induced membrane tissues, the number of MSCs among the BD-IM modeled rats was increased, whereas, a lower number was documented among BG modeled rats. Besides, we found that lentivirus-mediated over-expression of SDF-1 in BG modeled rats could activate the SDF-1/CXCR4 axis, mobilize MSCs into the defect area, and up-regulate the osteogenic proteins. CONCLUSIONS Collectively, our study speculated that up-regulation of SDF-1 promotes the mobilization and migration of MSCs through the activation of the SDF-1/CXCR4 signal pathway.
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Affiliation(s)
- Heli Zhang
- Department of Outpatient, The Second Hospital of Jilin University, Changchun, 130041, People's Republic of China
| | - Xijing Li
- Department of Emergency, The Second Hospital of Jilin University, Changchun, 130041, People's Republic of China
| | - Junfeng Li
- Department of Clinical Laboratory, The Second Hospital of Jilin University, Changchun, 130041, People's Republic of China
| | - Lili Zhong
- Jilin Provincial Key Laboratory On Molecular and Chemical Genetic, The Second Hospital of Jilin University, Changchun, 130041, People's Republic of China
| | - Xue Chen
- Department of Orthopedics, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, 130041, Jilin, People's Republic of China.
| | - Si Chen
- Department of Geriatric Medicine, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, 130041, Jilin, People's Republic of China.
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Tanner MC, Boxriker S, Haubruck P, Child C, Westhauser F, Fischer C, Schmidmaier G, Moghaddam A. Expression of VEGF in Peripheral Serum Is a Possible Prognostic Factor in Bone-Regeneration via Masquelet-Technique-A Pilot Study. J Clin Med 2021; 10:jcm10040776. [PMID: 33672081 PMCID: PMC7919640 DOI: 10.3390/jcm10040776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 11/26/2022] Open
Abstract
Two-step Masquelet-technique established a new procedure in the treatment of osseous defects, addressing prerequisites postulated by the “diamond concept”. Increase in blood perfusion and growth factors are enhanced by the “Masquelet-membrane”. To describe this, we measured serum levels of Vascular Endothelial Growth Factor (VEGF) of patients with atrophic non-unions of long bones undergoing Masquelet-technique. From over 500 non-union patients undergoing Masquelet-technique with prospective follow-up we randomly selected 30 patients. 23 were included, 7 lost to follow-up or excluded because of incomplete data. Serum was drawn at specified intervals before and after surgery. Patients were followed for at least 6 months after step 2. Classification into both groups was performed according to radiological results and clinical outcome 6 months after step 2. Concentration of VEGF in patients’ serum was performed via ELISA. 14 achieved osseous consolidation (responder group), 9 cases did not (non-responder). Responders showed a significant increase of serum-VEGF in the first and second week when compared to the preoperative values of step 1. Non-responders showed a significant increase of VEGF in the second week after Steps 1 and 2. Comparison of groups showed significantly higher increase of serum-VEGF week2 after step 1 and preoperative to step 2 for responders. Results show one possibility of illustrating therapeutic progress by monitoring growth factors and possibly allowing prognostic conclusions thereof. This might lead to a more targeted treatment protocol.
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Affiliation(s)
- Michael C. Tanner
- Center for Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany; (P.H.); (C.C.); (F.W.); (C.F.); (G.S.)
- Correspondence: ; Tel.: +49-6221-562-6398
| | - Sonja Boxriker
- Center of Orthopedics, Trauma & Sports medicine, Aschaffenburg-Alzenau Hospital, 63739 Aschaffenburg, Germany; (S.B.); (A.M.)
| | - Patrick Haubruck
- Center for Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany; (P.H.); (C.C.); (F.W.); (C.F.); (G.S.)
| | - Christopher Child
- Center for Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany; (P.H.); (C.C.); (F.W.); (C.F.); (G.S.)
| | - Fabian Westhauser
- Center for Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany; (P.H.); (C.C.); (F.W.); (C.F.); (G.S.)
| | - Christian Fischer
- Center for Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany; (P.H.); (C.C.); (F.W.); (C.F.); (G.S.)
| | - Gerhard Schmidmaier
- Center for Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany; (P.H.); (C.C.); (F.W.); (C.F.); (G.S.)
| | - Arash Moghaddam
- Center of Orthopedics, Trauma & Sports medicine, Aschaffenburg-Alzenau Hospital, 63739 Aschaffenburg, Germany; (S.B.); (A.M.)
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Pereira R, Perry WC, Crisologo PA, Liette MD, Hall B, Hafez Hassn SG, Masadeh S. Membrane-Induced Technique for the Management of Combined Soft Tissue and Osseous Defects. Clin Podiatr Med Surg 2021; 38:99-110. [PMID: 33220747 DOI: 10.1016/j.cpm.2020.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The induced membrane technique is a simple, effective, and reproducible treatment method for segmental bone defects. It is a 2-stage approach that requires eventual autologous bone graft to manage the deficit. The first stage requires debridement of all nonviable tissue while preserving a healthy soft tissue envelope. A polymethylmethacrylate is implanted between the osseous segments to maintain length. The osseous defect can be stabilized internally or externally. During the second stage, a vascularized induced membrane is formed and produces multiple growth factors. The induced membrane technique is a valuable option for limb salvage in cases of segmental bone defects.
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Affiliation(s)
- Ryan Pereira
- Private Practice, Anastasia Medical Group, 1301 Plantation Island Drive S, Suite 203A, Saint Augustine, FL 32080, USA
| | - William C Perry
- University of Cincinnati Medical Center, Cincinnati Veteran Affairs Medical Center, Veterans Affairs Hospital, 3200 Vine Street, Cincinnati, OH 45220, USA
| | - Peter A Crisologo
- Department of Surgery, Division of Podiatric Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Michael D Liette
- Division of Podiatric Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Bryan Hall
- Department of Surgery, Division of Podiatric Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Shawkat Ghazal Hafez Hassn
- General Organization of Teaching Hospitals and Neuromuscular Institute, 1 Altayar Fekry Street, Embaba, Gizza, Cairo 11865, Egypt
| | - Suhail Masadeh
- Division of Podiatric Surgery, University of Cincinnati Medical Center, Cincinnati. Veteran Affairs Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
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Kang Y, Wu Y, Ma Y, Liu J, Gu J, Zhou M, Wang Y, Lin F, Rui Y. "Primary free-flap tibial open fracture reconstruction with the Masquelet technique" and internal fixation. Injury 2020; 51:2970-2974. [PMID: 33097199 DOI: 10.1016/j.injury.2020.10.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 09/22/2020] [Accepted: 10/07/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Grade III open fractures of the lower extremity are serious injuries and are difficult to reconstruct. The optimal treatment for such injuries is unclear. We aimed to determine the safety and efficacy of orthoplastic reconstruction, using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation for Gustilo grade IIIB/C open tibial fractures. METHODS From April 2018 to April 2019, 15 patients, ranging from 19 to 72 years old, with Gustilo grade IIIB/C open fractures were treated using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation. This involved wound debridement and removal of free bone fragments, followed by bone cement packing of the defect, external fixation, and vacuum sealing drainage treatment. The final stage involved switching from external to internal fixation and wound repair using a free anterolateral thigh flap. Repair time ranged from 2 to 7 days. Flap size ranged from 25 × 15 cm2 to 13 × 7cm2. Hospital stay ranged from 11 to 50 days (mean, approximately 33.3 days). Bone cement was removed after 6-19 weeks and replaced with autogenic cancellous bone. RESULTS All flaps survived without incident. One patient experienced a wound infection, but there were no deep infections. For all patients, bone union was achieved after 4 to 7 months. CONCLUSION The use of a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation is a safe and effective procedure for reconstruction of Gustilo grade IIIB/C open fractures.
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Affiliation(s)
- Yongqiang Kang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yongwei Wu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yunhong Ma
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Jun Liu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Jun Gu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Ming Zhou
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yapeng Wang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Fang Lin
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yongjun Rui
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China.
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Abstract
Niobium (Nb), Titanium (Ti), and Zirconium (Zr) have attracted much attention as implant materials due to it's excellent mechanical properties and biocompatibility. However, little attention has been paid to high Nb-containing biomedical alloys. Here, the 50 wt.%Nb-XTi-Zr ternary alloy(x = 20wt.%, 30 wt.%, 40 wt.%) with relative density over 90% was prepared by powder metallurgy method. The massive α(Zr) distributed along the grain boundaries and lamellar β(Zr) appeared in the grains of β(Nb) in the 50 wt.%Nb-20wt.%Ti-Zr alloy. The acicular α phase is mainly distributed in the β-grain of 50 wt.%Nb-30wt.%Ti-Zr alloy. And α(Ti)-colonies in the β-grains and continuous α(Ti)GB at β-grain boundary can be observed in the 50 wt.%Nb-40wt.%Ti-Zr alloy. Comparing with Nb-20wt.%Ti-Zr alloy and 50 wt.%Nb-40wt.%Ti-Zr alloy, the 50 wt.%Nb-30wt.%Ti-Zr alloy showed lower Vickers hardness and elastic modulus. Furthermore, the as-sintered 50 wt.%Nb-XTi-Zr alloy promoted the cell proliferation and cell adhesion of MG-63 cells on the surface of alloys. In conclusion, the 50 wt.%Nb-XTi-Zr alloy combines excellent mechanical and biological properties, and the 50 wt.%Nb-30wt.%Ti-Zr alloy with lower elastic modulus (close to the bone) is a more promising candidate for bone implant material.
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Affiliation(s)
- Taomei Zhang
- State Key Laboratory of Powder Metallurgy, Central South University, Changsha, PR China
| | - Pinghua Ou
- State Key Laboratory of Powder Metallurgy, Central South University, Changsha, PR China
| | - Jianming Ruan
- State Key Laboratory of Powder Metallurgy, Central South University, Changsha, PR China
| | - Hailin Yang
- State Key Laboratory of Powder Metallurgy, Central South University, Changsha, PR China
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Lammens J, Maréchal M, Delport H, Geris L, Oppermann H, Vukicevic S, Luyten FP. A cell-based combination product for the repair of large bone defects. Bone 2020; 138:115511. [PMID: 32599225 DOI: 10.1016/j.bone.2020.115511] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/14/2020] [Accepted: 06/14/2020] [Indexed: 01/19/2023]
Abstract
Regenerative cell-based implants using periosteum-derived stem cells were developed for the treatment of large 3 cm fresh and 4.5 centimeter biological compromised bone gaps in a tibial sheep model and compared with an acellular ceramic-collagen void filler. It was hypothesized that the latter is insufficient to heal large skeletal defects due to reduced endogenous biological potency. To this purpose a comparison was made between the ceramic dicalciumphosphate scaffold (CopiOs®) as such, the same ceramic coated with clinical grade Bone Morphogenetic Protein 2 and 6 (BMP) only or a BMP coated cell-seeded combination product. These implants were evaluated in 2 sheep models, a fresh 3 cm critical size tibial defect and a 4.5 cm biologically exhausted tibial defect. For the groups in which growth factors were applied, BMP-6 was chosen at a dose of 344 μg for 3 cm and 1.500 μg or 3.800 μg for 4.5 cm defects. An additional group in the 4.5 cm defect was tested using BMP-2 in a dose of 1.500 μg. For all the cell based implants autologous periosteum-derived cells were used which were cultured in monolayer during 6 weeks. For the fresh defect 408 million cells and for the biologically exhausted tibial defect 612 million cells were drop-seeded on the BMP coated scaffolds. Bone healing was studied during 16 weeks postimplantation, using standard radiographs. While fresh defects responded to all treatments, regardless the use of cells, the biologically hampered defects responded in half of the cases and only if the BMP-cell combination product was used, supporting the concept that cell-based therapies may become attractive in treating defects with a compromised biological status.
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Affiliation(s)
- Johan Lammens
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; Prometheus, Division of Skeletal Tissue Engineering of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Marina Maréchal
- Prometheus, Division of Skeletal Tissue Engineering of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Skeletal Biology and Engineering Research Center, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Hendrik Delport
- Prometheus, Division of Skeletal Tissue Engineering of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Liesbet Geris
- Prometheus, Division of Skeletal Tissue Engineering of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Skeletal Biology and Engineering Research Center, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Mechanical Engineering, Biomechanics Section, KU Leuven, Celestijnenlaan 300, 3001 Heverlee (Leuven), Belgium; Biomechanics Research Unit, GIGA In silico medicine, University of Liège, Quartier Hôpital, Avenue de l'Hôpital 1, 4000 Liège 1, Belgium
| | - Hermann Oppermann
- Genera Research, Svetonedeljska cesta 2, 10436 Kalinovica, Sveta Nedelja, Croatia
| | - Slobodan Vukicevic
- Laboratory for Mineralized Tissues, Center for Translational and Clinical Research, School of Medicine, University of Zagreb, Šalata ul. 2, 10000 Zagreb, Croatia
| | - Frank P Luyten
- Prometheus, Division of Skeletal Tissue Engineering of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Skeletal Biology and Engineering Research Center, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Outcome of Induced Membrane Technique in Treatment of failed previously operated Congenital Pseudarthrosis of the Tibia. Orthop Traumatol Surg Res 2020; 106:813-818. [PMID: 32249159 DOI: 10.1016/j.otsr.2019.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although a remarkable success in the treatment of congenital pseudarthrosis tibia (CPT) had been achieved, failure rate is still high and the likelihood of amputation is still considerable. The current study evaluates the outcome of induced membrane technique in the treatment of failed previously operated patients of congenital pseudarthrosis of the tibia. We hypothesized that induced membrane technique will improve union rates in CPT with failed previous multiple operations. PATIENTS AND METHODS Nineteen consecutive patients of failed previously operated CPT were prospectively included in the study. All patients were treated by induced membrane technique with autogenous free non-vascularized fibular strut graft augmented by autogenous iliac graft and fixed by intramedullary K-Wire as well as Ilizarov external fixator. RESULTS The mean interval between the 1st and 2nd stages of the procedure was 4.9 weeks. Sound union was achieved in all cases in a mean time of 25.3 weeks. The mean follow up period was 5.02 years (range, 2.4-6.5). No refracture was documented till last follow up. CONCLUSION Induced membrane technique had proved as a successful method in the treatment of failed previously operated CPT with a satisfactory outcome and low complication rates. LEVEL OF EVIDENCE IV.
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Baud A, Flecher X, Rochwerger RA, Mattei JC, Argenson JN. Comparing the outcomes of the induced membrane technique between the tibia and femur: Retrospective single-center study of 33 patients. Orthop Traumatol Surg Res 2020; 106:789-796. [PMID: 32376202 DOI: 10.1016/j.otsr.2019.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/10/2019] [Accepted: 08/22/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Bone defects are challenging to treat surgically. The primary objective of our study was to compare the union rate and time to union between the tibia and femur when using the induced membrane technique. The secondary objective was to document how failures were managed. MATERIAL AND METHODS This retrospective, single-center study involved 33 patients (23 men, 10 women) who were older than 18 years of age. They were treated surgically for a leg fracture or long bone nonunion (22 tibia, 11 femur) using the induced membrane technique between January 2011 and December 2016 and had a complete follow-up. The minimum follow-up was 1 year for fractures and 2 years for non-union cases. Bone union was defined as the presence of at least two cortices with bridging on two radiographic views and return to full weight bearing. RESULTS The mean patient age was 38.3±15.5 years (18-72). The mean bone defect size was 7.9±5.0cm (2.3-18.0). The mean follow-up was 3.3±1.8 years (1-7.2). The union rate was 61% (20 patients). The mean time to union was 10±6.4 months (3-23). The time to union was significantly longer in the tibia (11.6±6.9 months [3-23]) than in the femur (6.3±2.9 months [3.4-10.3]) (p=0.025). The failure rate did not differ between the tibia and femur. Nine of the 13 patients (69%) in which the treatment failed were reoperated; 7 of them underwent nonunion treatment (78%) and 2 underwent amputation (22%). The other 4 patients were waiting for an infection to resolve before being reoperated. CONCLUSION The induced membrane technique is an effective surgical procedure for large bone defects in both the tibia and femur. However, the time to union was shorter in the femur than the tibia in our cohort. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Alexandre Baud
- Orthopaedic and Traumatology Surgery, Hôpital Nord Marseille, 53, chemin des Bourrely, 13015 Marseille, France.
| | - Xavier Flecher
- Orthopaedic and Traumatology Surgery, Hôpital Nord Marseille, 53, chemin des Bourrely, 13015 Marseille, France
| | | | - Jean-Camille Mattei
- Orthopaedic and Traumatology Surgery, Hôpital Nord Marseille, 53, chemin des Bourrely, 13015 Marseille, France
| | - Jean Noël Argenson
- Orthopaedic and Traumatology Surgery, Hôpital Nord Marseille, 53, chemin des Bourrely, 13015 Marseille, France
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Klein C, Monet M, Barbier V, Vanlaeys A, Masquelet AC, Gouron R, Mentaverri R. The Masquelet technique: Current concepts, animal models, and perspectives. J Tissue Eng Regen Med 2020; 14:1349-1359. [PMID: 32621637 DOI: 10.1002/term.3097] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022]
Abstract
Bone reconstruction within a critical-sized defect remains a real challenge in orthopedic surgery. The Masquelet technique is an innovative, two-step therapeutic approach for bone reconstruction in which the placement of a poly (methylmethacrylate) spacer into the bone defect induces the neo-formation of a tissue called "induced membrane." This surgical technique has many advantages and is often preferred to a vascularized bone flap or Ilizarov's technique. Although the Masquelet technique has achieved high clinical success rates since its development by Alain-Charles Masquelet in the early 2000s, very little is known about how the process works, and few animal models of membrane induction have been developed. Our successful use of this technique in the clinic and our interest in the mechanisms of tissue regeneration (notably bone regeneration) prompted us to develop a surgical model of the Masquelet technique in rats. Here, we provide a comprehensive review of the literature on animal models of membrane induction, encompassing the defect site, the surgical procedure, and the histologic and osteogenic properties of the induced membrane. We also discuss the advantages and disadvantages of those models to facilitate efforts in characterizing the complex biological mechanisms that underlie membrane induction.
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Affiliation(s)
- Céline Klein
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Michael Monet
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Vincent Barbier
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Alison Vanlaeys
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Alain-Charles Masquelet
- Service de Chirurgie Orthopédique, Traumatologie et Chirurgie de la Main, Saint-Antoine Hospital, Paris, France
| | - Richard Gouron
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Romuald Mentaverri
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France.,Department of Biochemistry and Endocrine Biology, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France
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Abdulkarim A, Hu SY, Walker BR, Krkovic M. Cambridge experience in spontaneous bone regeneration after traumatic segmental bone defect: a case series and review of literature. BMJ Case Rep 2020; 13:13/4/e232482. [PMID: 32327456 DOI: 10.1136/bcr-2019-232482] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
High-energy traumatic long bone defects are some of the most challenging to reconstruct. Although cases of spontaneous bone regeneration in these defects have been reported, we are aware of no management guidelines or recommendations for when spontaneous bone regeneration should be considered a viable management option. We aim to identify how certain patient characteristics and surgical factors may help predict spontaneous bone regeneration. A total of 26 cases with traumatic segmental defects were treated at our institution, with eight cases (30.8%) undergoing spontaneous regeneration. We discuss four in detail. Six (75%) reported a degree of periosteal preservation, four (50%) were associated with traumatic brain injury and none were complicated by infection. The average time to spontaneous bone regeneration was 2.06 months. According to our cases, patients with favourable characteristics may benefit from delaying surgical treatment by 6 weeks to monitor for any signs of spontaneous bone formation.
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Affiliation(s)
- Ali Abdulkarim
- Department Of Trauma and Orthopaedic Surgery, Cambridge University Hospital / Addenbrooke's Hospital, Cambridge, UK
| | - Shu Yang Hu
- Graduate Entry Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brendon R Walker
- Graduate Entry Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Matija Krkovic
- Department Of Trauma and Orthopaedic Surgery, Cambridge University Hospital / Addenbrooke's Hospital, Cambridge, UK
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Yao J, Liu Z, Ma W, Dong W, Wang Y, Zhang H, Zhang M, Sun D. Three-Dimensional Coating of SF/PLGA Coaxial Nanofiber Membranes on Surfaces of Calcium Phosphate Cement for Enhanced Bone Regeneration. ACS Biomater Sci Eng 2020; 6:2970-2984. [PMID: 33463266 DOI: 10.1021/acsbiomaterials.9b01729] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Calcium phosphate cements (CPCs) have been widely used for the study of bone regeneration because of their excellent physical and chemical properties, but poor biocompatibility and lack of osteoinductivity limit potential clinical applications. To overcome these limitations, and based on our previous research, CPC scaffolds were prepared with CPC as the principal material and polyethylene glycol (PEG) as a porogen to introduce interconnected macropores. Using a bespoke electrospinning auxiliary receiver, silk fibroin (SF)/poly(lactide-co-glycolide) (PLGA) coaxial nanofibers containing dexamethasone (DXM) and recombinant human bone morphogenetic protein-2 (rhBMP2) were fabricated which were coated on the surface of the CPC. By comparing the surface morphology by SEM, hydrophilicity, results of FTIR spectroscopy, and mechanical properties of the composite materials fabricated using different electrospinning times (20, 40, 60 min), the CPC surface constructed by electrospinning for 40 min was found to exhibit the most appropriate physical and chemical properties. Therefore, composite materials were built for further study by electrospinning for 40 min. The osteogenic capacity of the SF/PLGA/CPC, SF-DXM/PLGA/CPC, and SF-DXM/PLGA-rhBMP2/CPC scaffolds was evaluated by in vitro cell culture with rat bone marrow mesenchymal stem cells (BMSCs) and using a rat cranial defect repair model. ALP activity, calcium deposition levels, upregulation of osteogenic genes, and bone regeneration in skull defects in rats with SF-DXM/PLGA-rhBMP2/CPC implants were significantly higher than in rats implanted with the other scaffolds. These results suggest that drug-loaded coaxial nanofiber coatings prepared on a CPC surface can continuously and effectively release bioactive drugs and further stimulate osteogenesis. Therefore, the SF-DXM/PLGA-rhBMP2/CPC scaffolds prepared in this study demonstrated the most significant potential for the treatment of bone defects.
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Affiliation(s)
- Jihang Yao
- Norman Bethune First Hospital, Jilin University, Changchun 130021, P. R. China
| | - Zhewen Liu
- Norman Bethune First Hospital, Jilin University, Changchun 130021, P. R. China
| | - Wendi Ma
- Alan G. MacDiarmid Laboratory, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Wenying Dong
- Alan G. MacDiarmid Laboratory, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Yilong Wang
- Alan G. MacDiarmid Laboratory, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Haibo Zhang
- Alan G. MacDiarmid Laboratory, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Mei Zhang
- Alan G. MacDiarmid Laboratory, College of Chemistry, Jilin University, Changchun 130012, P. R. China
| | - Dahui Sun
- Norman Bethune First Hospital, Jilin University, Changchun 130021, P. R. China
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Zhang C, Zhu C, Yu G, Deng K, Yu L. Management of Infected Bone Defects of the Lower Extremities by Three-Stage Induced Membrane Technique. Med Sci Monit 2020; 26:e919925. [PMID: 32047141 PMCID: PMC7034405 DOI: 10.12659/msm.919925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/14/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Infected bone defects are therapeutic challenges. Although the induced membrane technique has been used for this problem, there is a 3% to 20.7% failure to eradicate infection, and there have been few reports about its use in tuberculous infection. We present our three-stage induced membrane technique (TSIMT) for treating infected bone defects of the lower extremity. MATERIAL AND METHODS Forty-one adult patients with infected bone defects of the lower extremities treated by TSIMT were included in a retrospective case-series study between January 2013 and June 2018. The clinical, imaging and laboratory assessment outcomes were analyzed. RESULTS In the first stage, 3 patients had ankle tuberculous bone defects and 17 patients underwent 2-4 debridements. In the second stage, the average bone defect was 6.0 cm; 1 patient needed an anterolateral thigh flap to cover the wound. In the third stage, 10 patients underwent autograft mixed allograft, and 18 cases used internal fixation. The mean follow-up period was 23.3 months. All patients achieved bone union and clinical eradication of infection. Changes in Lower Extremity Functional Scale (LEFS) scores after 1 year of TSIMT and bone union time are associated with advanced age, longer duration of infected bone defects, active smoking, and external fixation (p<0.05), but are not dependent on bone defect size, debridement times, type of bone graft, or spacer-placing time (p>0.05). CONCLUSIONS TSIMT is effective in treating infected bone defects of the lower extremities. Advanced age, longer duration of infected bone defects, active smoking, and external fixation adversely affect bone union and recovery of infected extremities in a limited time span.
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Jin L, Li P, Wang YC, Feng L, Xu R, Yang DB, Yao XH. Studies of Superb Microvascular Imaging and Contrast-Enhanced Ultrasonography in the Evaluation of Vascularization in Early Bone Regeneration. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2963-2971. [PMID: 30945763 DOI: 10.1002/jum.15002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 02/17/2019] [Accepted: 02/26/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The aim of this study was to investigate value of superb microvascular imaging (SMI) and contrast-enhanced ultrasonography (CEUS) in evaluating the neovascularization of early bone regeneration. METHODS Twenty-five Sprague-Dawley male rats were implanted with recombinant human bone morphogenetic protein-2/calcium phosphate cement (rhBMP-2/) in the muscle space of the left hind limb near the femoral head to establish the rat model of intramuscular ectopic osteogenesis. Ultrasonography and pathologic analysis were performed on the 3rd, 7th, 14th, 21st, and 28th days after modeling. Two-dimensional ultrasonography, SMI, and CEUS were used to assess neovascularization and bone formation. RESULTS Pathologic examination showed that different levels of neovascularization were observed in the graft bone over time after modeling, which increased significantly from the 3rd to 14th day, and then gradually decreased. CEUS and SMI showed no obvious microvessels inside the graft bone on the 3rd day. On the 7th day after modeling, a small number of neovascular vessels were observed around the graft bone. On the 14th day, neovascularization was observed in both the peripheral and inner parts of the graft bone. The number of neovascular vessels inside the graft bone had decreased gradually by the 21st and 28th days. The results of SMI and CEUS indexes showed that the vascular index, peak intensity, enhancement intensity, and enhancement rate first increased and then decreased with time. Their peak points were found on the 14th day. Arrival time, time to peak, and enhancement time decreased gradually over time (P < .05). CONCLUSION The combined application of SMI and CEUS may be useful in evaluating the neovascularization of early osteoanagenesis.
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Affiliation(s)
- Lin Jin
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Ping Li
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Ying-Chun Wang
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Lan Feng
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Rong Xu
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - De-Bin Yang
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Xiao-Hua Yao
- Department of Ultrasound, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China
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32
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Wang J, Yin Q, Gu S, Wu Y, Rui Y. Induced membrane technique in the treatment of infectious bone defect: A clinical analysis. Orthop Traumatol Surg Res 2019; 105:535-539. [PMID: 30858038 DOI: 10.1016/j.otsr.2019.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/29/2018] [Accepted: 01/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND At present, it is still a challenge for repairing a wide range of bone defect caused by various reasons. We aimed to investigate the effect of induced membrane technique in the treatment of infectious bone defect. PATIENTS AND METHODS The clinical data of twenty-one patients with infectious bone defect that received induced membrane technique treatment from January 2008 to August 2017 were collected for this study. The complications were recorded, and the bone defect healing and the recovery of joint function were evaluated by Paley method. The adjacent joint activities were also evaluated. RESULTS One month after the first stage of surgery, one case had wound dehiscence, and others healed well without infection. Six cases had induced membrane injury during the second stage of surgery, and 4 of them received induced membrane wrapping reconstruction. At the last follow-up, bone defect healing was excellent, the joint function was restored (the rate of excellent and good was 90.5%). The joint range of motion recovered well and the rate of excellent and good was 81.0%. CONCLUSION Induction membrane technique in the treatment of infectious bone defect has advantages of simple operation, rapid healing of bone defects, and low recurrence rate of infection.
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Affiliation(s)
- Jianbing Wang
- Department of Orthopaedics, Wuxi the Ninth People's Hospital Affiliated to Soochow University, No. 999 Liangxi Road, Wuxi 214062, Jiangsu, China
| | - Qudong Yin
- Department of Orthopaedics, Wuxi the Ninth People's Hospital Affiliated to Soochow University, No. 999 Liangxi Road, Wuxi 214062, Jiangsu, China
| | - Sanjun Gu
- Department of Orthopaedics, Wuxi the Ninth People's Hospital Affiliated to Soochow University, No. 999 Liangxi Road, Wuxi 214062, Jiangsu, China
| | - Yongwei Wu
- Department of Orthopaedics, Wuxi the Ninth People's Hospital Affiliated to Soochow University, No. 999 Liangxi Road, Wuxi 214062, Jiangsu, China
| | - Yongjun Rui
- Department of Orthopaedics, Wuxi the Ninth People's Hospital Affiliated to Soochow University, No. 999 Liangxi Road, Wuxi 214062, Jiangsu, China.
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Results of the Induced Membrane Technique in the Management of Traumatic Bone Loss in the Lower Limb: A Cohort Study. J Orthop Trauma 2019; 33:131-136. [PMID: 30562247 DOI: 10.1097/bot.0000000000001384] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To present our technique and early results using the Masquelet technique. DESIGN Retrospective cohort study. PATIENTS/PARTICIPANTS Thirteen patients with 14 open fractures of the femur and tibia were included between November 2013 and December 2014. INTERVENTION A Masquelet technique was used to manage the open fractures. MAIN OUTCOME MEASURE Infection and union rate. RESULTS The mean follow-up was 17 months. The mean bone defect was 56.6 mm. Eight fractures (57.1%) progressed to union at an average of 42.1 weeks. Infection developed in 3 fractures (21.4%). Overall, the induced membrane technique was abandoned in 5 (35.7%) cases. CONCLUSIONS The induced membrane technique showed a substantial rate of failure in the acute trauma setting in the lower limb. In the absence of sound published evidence, the authors now use the technique in selected cases only. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Toth Z, Roi M, Evans E, Watson JT, Nicolaou D, McBride-Gagyi S. Masquelet Technique: Effects of Spacer Material and Micro-topography on Factor Expression and Bone Regeneration. Ann Biomed Eng 2019; 47:174-189. [PMID: 30259220 PMCID: PMC6318020 DOI: 10.1007/s10439-018-02137-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/19/2018] [Indexed: 12/12/2022]
Abstract
We and others have shown that changing surface characteristics of the spacer implanted during the first Masquelet stage alters some aspects of membrane development. Previously we demonstrated that titanium (TI) spacers create membranes that are better barriers to movement of solutes > 70 kDa in size than polymethyl methacrylate (PMMA) induced-membranes, and roughening creates more mechanically compliant membranes. However, it is unclear if these alterations affect the membrane's biochemical environment or bone regeneration during the second stage. Ten-week-old, male Sprague-Dawley rats underwent an initial surgery to create an externally stabilized 6 mm femoral defect. PMMA or TI spacers with smooth (~ 1 μm) or roughened (~ 8 μm) surfaces were implanted. Four weeks later, rats were either euthanized for membrane harvest or underwent the second Masquelet surgery. TI spacers induced thicker membranes that were similar in structure and biochemical expression. All membranes were bilayered with the inner layer having increased factor expression [bone morphogenetic protein 2 (BMP2), transforming growth factor beta (TGFβ), interleukin 6 (IL6), and vascular endothelial growth factor (VEGF)]. Roughening increased overall IL6 levels. Ten-weeks post-engraftment, PMMA-smooth induced membranes better supported bone regeneration (60% union). The other groups only had 1 or 2 that united (9-22%). There were no significant differences in any micro computed tomography or dynamic histology outcome. In conclusion, this study suggests that the membrane's important function in the Masquelet technique is not simply as a barrier. There is likely a critical biochemical, cellular, or vascular component as well.
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Affiliation(s)
- Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO, 63104, USA
| | - Matt Roi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO, 63104, USA
| | - Emily Evans
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO, 63104, USA
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO, 63104, USA
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO, 63104, USA
| | - Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO, 63104, USA.
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Zhao X, Yu L, Tao S, Deng L, Wei C, Wang B, Zhu S. [Treatment of severe distal humeral bone defects with three-dimensional printing technology]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1534-1539. [PMID: 30569679 PMCID: PMC8414236 DOI: 10.7507/1002-1892.201803008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 10/22/2018] [Indexed: 02/04/2023]
Abstract
Objective To explore the application of three-dimensional (3D) printing technology in precise and individualized surgical treatment of severe distal humeral bone defect. Methods Five patients with severe distal humeral bone defects were treated with customized 3D printing prostheses between December 2010 and December 2015. There were 4 males and 1 female, with an age of 23-57 years (mean, 35 years); and the length of the bone defect was 5-12 cm (mean, 8 cm). The cause of injury was mechanical injury in 2 cases and strangulation in 3 cases. All of them were the open fracture of Gustilo type Ⅲ. There were 2 cases of radial fracture, 1 case of cubital nerve injury, and 3 cases of radial nerve injury. The time from injury to one-stage operation was 6-18 hours (mean, 10 hours). The operation time, intraoperative blood loss, and intraoperative fluoroscopy were recorded. During follow-up, the anteroposterior and lateral X-ray films of the elbow joints were performed to identify whether there was prosthesis loosening; Mayo Elbow Performance Score (MEPS) and upper extremity Enneking score were used to evaluate limb function. Results The operation time was 140-190 minutes (mean, 165 minutes). The intraoperative blood loss was 310-490 mL (mean, 415 mL). The intraoperative fluoroscopy was 1-3 times (mean, 1.6 times). Five patients were followed up 14-38 months (mean, 21 months). The wound exudate occurred in 1 case and cured after anti-inflammatory local dressing change; the subcutaneous hematoma occurred in 1 case, and improved after color Doppler ultrasound guided puncture and drainage. The MEPS scores and the Enneking scores were all significantly improved when compared with preoperative ones ( P<0.05). Except MEPS score between 6 and 12 months after operation had no significant difference ( P>0.05), there were significant differences in MEPS scores and Enneking scores between the other time points ( P<0.05). During the follow-up, no prosthetic loosening or joint dislocation occurred. Conclusion 3D printing technology can achieve personalized treatment of severe distal humeral bone defects, obtain relatively good elbow joint function, and has less postoperative complications and satisfactory effectiveness.
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Affiliation(s)
- Xing Zhao
- Department of Orthopedics, Taihe Hospital of Shiyan, Shiyan Hubei, 442000, P.R.China;Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071, P.R.China
| | - Li Yu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071, P.R.China
| | - Shengxiang Tao
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071, P.R.China
| | - Linglong Deng
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071, P.R.China
| | - Chi Wei
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071, P.R.China
| | - Bing Wang
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071, P.R.China
| | - Shaobo Zhu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan Hubei, 430071,
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Grgurevic L, Oppermann H, Pecin M, Erjavec I, Capak H, Pauk M, Karlovic S, Kufner V, Lipar M, Bubic Spoljar J, Bordukalo-Niksic T, Maticic D, Peric M, Windhager R, Sampath TK, Vukicevic S. Recombinant Human Bone Morphogenetic Protein 6 Delivered Within Autologous Blood Coagulum Restores Critical Size Segmental Defects of Ulna in Rabbits. JBMR Plus 2018; 3:e10085. [PMID: 31131338 DOI: 10.1002/jbm4.10085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/29/2018] [Accepted: 12/16/2018] [Indexed: 12/21/2022] Open
Abstract
BMP2 and BMP7, which use bovine Achilles tendon-derived absorbable collagen sponge and bovine bone collagen as scaffold, respectively, have been approved as bone graft substitutes for orthopedic and dental indications. Here, we describe an osteoinductive autologous bone graft substitute (ABGS) that contains recombinant human BMP6 (rhBMP6) dispersed within autologous blood coagulum (ABC) scaffold. The ABGS is created as an injectable or implantable coagulum gel with rhBMP6 binding tightly to plasma proteins within fibrin meshwork, as examined by dot-blot assays, and is released slowly as an intact protein over 6 to 8 days, as assessed by ELISA. The biological activity of ABGS was examined in vivo in rats (Rattus norvegicus) and rabbits (Oryctolagus cuniculus). In a rat subcutaneous implant assay, ABGS induced endochondral bone formation, as observed by histology and micro-CT analyses. In the rabbit ulna segmental defect model, a reproducible and robust bone formation with complete bridging and restoration of the defect was observed, which is dose dependent, as determined by radiographs, micro-CT, and histological analyses. In ABGS, ABC scaffold provides a permissive environment for bone induction and contributes to the use of lower doses of rhBMP6 compared with BMP7 in bovine bone collagen as scaffold. The newly formed bone undergoes remodeling and establishes cortices uniformly that is restricted to implant site by bridging with host bone. In summary, ABC carrier containing rhBMP6 may serve as an osteoinductive autologous bone graft substitute for several orthopedic applications that include delayed and nonunion fractures, anterior and posterior lumbar interbody fusion, trauma, and nonunions associated with neurofibromatosis type I.
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Affiliation(s)
- Lovorka Grgurevic
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | | | - Marko Pecin
- Clinics for Surgery, Orthopedics, and Ophthalmology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Igor Erjavec
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Hrvoje Capak
- Department of Radiology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Martina Pauk
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Sven Karlovic
- Faculty of Food Technology and Biotechnology University of Zagreb Zagreb Croatia
| | - Vera Kufner
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Marija Lipar
- Clinics for Surgery, Orthopedics, and Ophthalmology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Jadranka Bubic Spoljar
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | | | - Drazen Maticic
- Clinics for Surgery, Orthopedics, and Ophthalmology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Mihaela Peric
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery Medical University of Vienna Vienna Austria
| | | | - Slobodan Vukicevic
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
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Ronga M, Cherubino M, Corona K, Fagetti A, Bertani B, Valdatta L, Mora R, Cherubino P. Induced membrane technique for the treatment of severe acute tibial bone loss: preliminary experience at medium-term follow-up. INTERNATIONAL ORTHOPAEDICS 2018; 43:209-215. [PMID: 30280216 DOI: 10.1007/s00264-018-4164-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Management of acute open tibial fractures with critical bone defect remains a challenge in trauma surgery. Few and heterogeneous cases have been reported about the treatment with the induced membrane technique. METHODS We prospectively evaluated three patients treated with the induced membrane technique for acute Gustilo IIIB tibial fractures with critical bone defect. Success treatment was defined by bone union with patient pain free. Clinical and radiological evaluations were performed regularly until healing, then annually and with a minimum follow-up of five years. RESULTS In all patients but one, a success was recorded, respectively, at four and six months. These two patients were pain free until the final follow-up, and no graft resorption or secondary complications related to the index surgery were observed. The third case was managed successfully with a bone transport technique. CONCLUSION The induced membrane technique is an alternative good option for the treatment of these severe lesions.
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Affiliation(s)
- Mario Ronga
- Department of Medicine and Health Sciences 'Vincenzo Tiberio', University of Molise, Via Giovanni Paolo II, 86100, Campobasso, Italy. .,Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy.
| | - Mario Cherubino
- Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Katia Corona
- Department of Medicine and Health Sciences 'Vincenzo Tiberio', University of Molise, Via Giovanni Paolo II, 86100, Campobasso, Italy
| | - Alessandro Fagetti
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Barbara Bertani
- Department of Orthopedics and Traumatology, University of Pavia, Pavia, Italy
| | - Luigi Valdatta
- Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Redento Mora
- Department of Orthopedics and Traumatology, University of Pavia, Pavia, Italy
| | - Paolo Cherubino
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
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Gaio N, Martino A, Toth Z, Watson JT, Nicolaou D, McBride-Gagyi S. Masquelet technique: The effect of altering implant material and topography on membrane matrix composition, mechanical and barrier properties in a rat defect model. J Biomech 2018; 72:53-62. [PMID: 29510858 PMCID: PMC5895482 DOI: 10.1016/j.jbiomech.2018.02.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/26/2022]
Abstract
The Masquelet technique is a surgical procedure to regenerate segmental bone defects. The two-phase treatment relies on the production of a vascularized foreign-body membrane to support bone grafts over three times larger than the traditional maximum. Historically, the procedure has always utilized a bone cement spacer to evoke membrane production. However, membrane formation can easily be effected by implant surface properties such as material and topology. This study sought to determine if the membrane's mechanical or barrier properties are affected by changing the spacer material to titanium or roughening the surface finish. Ten-week-old, male Sprague Dawley rats were given an externally stabilized, 6 mm femur defect which was filled with a pre-made spacer of bone cement (PMMA) or titanium (TI) with a smooth (∼1 μm) or roughened (∼8 μm) finish. After 4 weeks of implantation, the membranes were harvested, and the matrix composition, tensile mechanics, shrinkage, and barrier function was assessed. Roughening the spacers resulted in significantly more compliant membranes. TI spacers created membranes that inhibited solute transport more. There were no differences between groups in collagen or elastin distribution. This suggests that different membrane characteristics can be created by altering the spacer surface properties. Surgeons may unknowingly effecting membrane formation via bone cement preparation techniques.
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Affiliation(s)
- Natalie Gaio
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Alice Martino
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA.
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Inhibition of Dll4/Notch1 pathway promotes angiogenesis of Masquelet's induced membrane in rats. Exp Mol Med 2018; 50:1-15. [PMID: 29674611 PMCID: PMC5938037 DOI: 10.1038/s12276-018-0062-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/30/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
The Masquelet’s induced membrane technique for repairing bone defects has been demonstrated to be a promising treatment strategy. Previous studies have shown that the vessel density of induced membrane is decreased in the late stage of membrane formation, which consequently disrupts the bone healing process. However, relatively little is known about certain mechanisms of vessel degeneration in the induced membrane tissue and whether promotion of angiogenesis in induced membranes can improve bone regeneration. Here, we showed that the Delta-like ligand 4/ Notch homolog 1 (Dll4/Notch1) pathway was relatively activated in the late stage of induced membrane, especially at the subcutaneous site. Then, DAPT, a classical γ-secretase inhibitor, was applied to specifically inhibit Notch1 activation, followed by up-regulation of vascular endothelial growth factor receptor 2 (VEGFR2) and CD31 expression. DAPT-modified induced membranes were further confirmed to contribute to bone regeneration after autogenous bone grafting. Finally, in vitro experiments revealed that knocking down Notch1 contributed to the functional improvement of endothelial progenitor cells (EPCs) and that DAPT-treated induced membrane tissue was more favorable for angiogenesis of EPCs compared with the vehicle group. In conclusion, the present findings demonstrate that Dll4/Notch1 signaling is negatively associated with the vessel density of induced membrane. Pharmacological inhibition of Notch1 attenuated the vessel degeneration of induced membrane both in vitro and in vivo, which consequently improved bone formation at the bone defect site and graft resorption at the subcutaneous site. Repairs to serious bone injuries may be improved by blocking a signaling pathway that causes newly forming membranes to fail. Masquelet’s technique involves placing acrylic spacers in areas of bone damage, inducing the formation of vascularised membranes which encourage the body to accept bone grafts. However, sometimes Masquelet’s membranes do not form correctly, leading to weaknesses in bone repairs and potential graft rejection. In experiments on rats, Qian Tang from Wenzhou Medical University, China, and coworkers found that a particular signaling pathway, D114/Notch1, was upregulated around 6 weeks post-operation, reducing blood vessel density and limiting new vessel growth, weakening the membranes. The team inhibited this pathway using an existing therapy that prevents blood clots. This treatment improved bone repairs by promoting the formation and function of blood vessels in membranes.
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Liu F, Huang RK, Xie M, Pan H, Zhao JJ, Lei B. Use of Masquelet's technique for treating the first metatarsophalangeal joint in cases of gout combined with a massive bone defect. Foot Ankle Surg 2018; 24:159-163. [PMID: 29409218 DOI: 10.1016/j.fas.2017.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 01/09/2017] [Accepted: 01/30/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND To examine the safety and efficacy of Masquelet's technique as a surgical method for treating the first metatarsophalangeal joint in cases of gout accompanied by a massive bone defect. METHODS From January 2010 to January 2016, eleven patients (7 males and 4 females; mean age 33.1 years; range, 23-43 years) received surgical treatment for a first metatarsophalangeal joint tophus which caused a serious bone defect. The first metatarsophalangeal bone defects ranged from 3-6cm, or nearly 50% of the length of normal bone. During the first stage of Masquelet's technique, we removed the tophus and infused that area with bone cement that contained antibiotics. Two months later, we performed the second stage, in which the prosthesis was replaced with iliac cancellous bone, and the operated area was stabilized via locking plate fixation. RESULTS All of the surgeries were successful, and the 11 patients were followed up for an average of 10.9 months. Postoperative evaluations showed that 10 of the 11 patients healed between 9 and 14 days after the initial surgery. Bone fusion occurred between 2.3 and 3.6 months after the operation, and the average healing time was 3.0 months. One foot wound became infected, but healed after vacuum aspiration. When the American Association of Foot and Ankle Surgery Maryland Foot scoring system was used to evaluate the foot function of the 11 patients prior to surgery, all 11 patients were graded as "failures." Following surgery, 2 patients were graded excellent, 5 were good, 3 were fair, and only 1 patient failed. The total combined excellent and good rate was 63.6%. The total mean Maryland scores pre- and post-surgery were 27.8 points and 74.1 points, respectively; thus the average patient score increased by 46.3 points. CONCLUSIONS Joints with advanced tophus nodules develop segmental bone defects. Masquelet's technique is an effective method for treating such nodules and their associated bone defects.
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Affiliation(s)
- Feng Liu
- Department of Orthopedics, Wuhan Pu'Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruo-Kun Huang
- Department of Orthopedics, Wuhan Pu'Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ming Xie
- Department of Orthopedics, Wuhan Pu'Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Pan
- Department of Orthopedics, Wuhan Pu'Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing-Jing Zhao
- Department of Orthopedics, Wuhan Pu'Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Lei
- Department of Orthopedics, Wuhan Pu'Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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McBride-Gagyi S, Toth Z, Kim D, Ip V, Evans E, Watson JT, Nicolaou D. Altering spacer material affects bone regeneration in the Masquelet technique in a rat femoral defect. J Orthop Res 2018; 36:10.1002/jor.23866. [PMID: 29424019 PMCID: PMC6785358 DOI: 10.1002/jor.23866] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/30/2018] [Indexed: 02/04/2023]
Abstract
The Masquelet technique depends on pre-development of a foreign-body membrane to support bone regeneration with grafts over three times larger than the traditional maximum. To date, the procedure has always used spacers made of bone cement, which is the polymer polymethyl methacrylate (PMMA), to induce the foreign-body membrane. This study sought to compare (i) morphology, factor expression, and cellularity in membranes formed by PMMA, titanium, and polyvinyl alcohol sponge (PVA) spacers in the Masquelet milieu and (ii) subsequent bone regeneration in the same groups. Ten-week-old, male Sprague-Dawley rats were given an externally stabilized, 6 mm femur defect, and a pre-made spacer of PMMA, titanium, or PVA was implanted. All animals were given 4 weeks to form a membrane, and those receiving an isograft were given 10 weeks post-implantation to union. All samples were scanned with microCT to measure phase 1 and phase 2 bone formation. Membrane samples were processed for histology to measure membrane morphology, cellularity, and expression of the factors BMP2, TGFβ, VEGF, and IL6. PMMA and titanium spacers created almost identical membranes and phase 1 bone. PVA spacers were uniformly infiltrated with tissue and cells and did not form a distinct membrane. There were no quantitative differences in phase 2 bone formation. However, PMMA induced membranes supported functional union in 6 of 7 samples while a majority of titanium and PVA groups failed to achieve the same. Spacer material can alter the membrane enough to disrupt phase 2 bone formation. The membrane's role in bone regeneration is likely more than just as a physical barrier. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Daniel Kim
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Victoria Ip
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Emily Evans
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
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Bernhardsson M, Tätting L, Sandberg O, Schilcher J, Aspenberg P. Marrow compartment contribution to cortical defect healing. Acta Orthop 2018; 89:119-123. [PMID: 28946782 PMCID: PMC5810819 DOI: 10.1080/17453674.2017.1382280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Healing of shaft fractures is commonly described as regards external callus. We wanted to clarify the role of the bone marrow compartment in the healing of stable shaft fractures. Patients and methods - A longitudinal furrow was milled along the longitudinal axis of the femoral shaft in mice. The exposed bone marrow under the furrow was scooped out. The mice were then randomized to no further treatment, or to receiving 2 silicone plugs in the medullary canal distal and proximal to the defect. The plugs isolated the remaining marrow from contact with the defect. Results were studied with histology and flow cytometry. Results - Without silicone plugs, the marrow defect was filled with new bone marrow-like tissue by day 5, and new bone was seen already on day 10. The new bone was seen only at the level of the cortical injury, where it seemed to form simultaneously in the entire region of the removed cortex. The new bone seemed not to invade the marrow compartment, and there was a sharp edge between new bone and marrow. The regenerated marrow was similar to uninjured marrow, but contained considerably more cells. In the specimens with plugs, the marrow compartment was either filled with loose scar tissue, or empty, and there was only minimal bone formation, mainly located around the edges of the cortical injury. Interpretation - Marrow regeneration in the defect seemed to be a prerequisite for normal cortical healing. Shaft fracture treatment should perhaps pay more attention to the local bone marrow.
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Luangphakdy V, Elizabeth Pluhar G, Piuzzi NS, D’Alleyrand JC, Carlson CS, Bechtold JE, Forsberg J, Muschler GF. The Effect of Surgical Technique and Spacer Texture on Bone Regeneration: A Caprine Study Using the Masquelet Technique. Clin Orthop Relat Res 2017; 475. [PMID: 28634897 PMCID: PMC5599407 DOI: 10.1007/s11999-017-5420-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Masquelet-induced-membrane technique is a commonly used method for treating segmental bone defects. However, there are no established clinical standards for management of the induced membrane before grafting. QUESTIONS/PURPOSES Two clinically based theories were tested in a chronic caprine tibial defect model: (1) a textured spacer that increases the induced-membrane surface area will increase bone regeneration; and (2) surgical scraping to remove a thin tissue layer of the inner induced-membrane surface will enhance bone formation. METHODS Thirty-two skeletally mature female goats were assigned to four groups: smooth spacer with or without membrane scraping and textured spacer with or without membrane scraping. During an initial surgical procedure (unilateral, left tibia), a defect was created excising bone (5 cm), periosteum (9 cm), and muscle (10 g). Segments initially were stabilized with an intramedullary rod and an antibiotic-impregnated polymethylmethacrylate spacer with a smooth or textured surface. Four weeks later, the spacer was removed and the induced-membrane was either scraped or left intact before bone grafting. Bone formation was assessed using micro-CT (total bone volume in 2.5-cm central defect region) as the primary outcome; radiographs and histologic analysis as secondary outcomes, with the reviewer blinded to the treatment groups of the samples being assessed 12 weeks after grafting. All statistical tests were performed using a linear mixed effects model approach. RESULTS Micro-CT analysis showed greater bone formation in defects with scraped induced membrane (mean, 3034.5 mm3; median, 1928.0 mm3; quartile [Q]1-Q3, 273.3-2921.1 mm3) compared with defects with intact induced membrane (mean, 1709.5 mm3; median, 473.8 mm3; Q1-Q3, 132.2-1272.3 mm3; p = 0.034). There was no difference in bone formation between textured spacers (mean, 2405.5 mm3; median, 772.7 mm3; Q1-Q3, 195.9-2743.8 mm3) and smooth spacers (mean, 2473.2 mm3; median, 1143.6 mm3; Q1-Q3, 230.2-451.1 mm3; p = 0.917). CONCLUSIONS Scraping the induced-membrane surface to remove the innermost layer of the induced-membrane increased bone regeneration. A textured spacer that increased the induced-membrane surface area had no effect on bone regeneration. CLINICAL RELEVANCE Scraping the induced membrane during the second stage of the Masquelet technique may be a rapid and simple means of improving healing of segmental bone defects, which needs to be confirmed clinically.
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Affiliation(s)
- Viviane Luangphakdy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH USA
| | - G. Elizabeth Pluhar
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN USA
| | - Nicolás S. Piuzzi
- Department of Orthopaedic Surgery and Biomedical Engineering (ND20), Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA ,Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jean-Claude D’Alleyrand
- Department of Surgery, Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Cathy S. Carlson
- Department of Veterinary Population Medicine, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN USA
| | - Joan E. Bechtold
- Department of Orthopaedic Surgery, Minneapolis Medical Research Foundation and University of Minnesota, Saint Paul, MN USA
| | - Jonathan Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA
| | - George F. Muschler
- Department of Orthopaedic Surgery and Biomedical Engineering (ND20), Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
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Lui YF, Ip WY. Biological Evaluation of Flexible Polyurethane/Poly l-Lactic Acid Composite Scaffold as a Potential Filler for Bone Regeneration. MATERIALS 2017; 10:ma10091042. [PMID: 28902161 PMCID: PMC5615697 DOI: 10.3390/ma10091042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/19/2017] [Accepted: 08/31/2017] [Indexed: 12/28/2022]
Abstract
Degradable bone graft substitute for large-volume bone defects is a continuously developing field in orthopedics. With the advance in biomaterial in past decades, a wide range of new materials has been investigated for their potential in this application. When compared to common biopolymers within the field such as PLA or PCL, elastomers such as polyurethane offer some unique advantages in terms of flexibility. In cases of bone defect treatments, a flexible soft filler can help to establish an intimate contact with surrounding bones to provide a stable bone-material interface for cell proliferation and ingrowth of tissue. In this study, a porous filler based on segmented polyurethane incorporated with poly l-lactic acid was synthesized by a phase inverse salt leaching method. The filler was put through in vitro and in vivo tests to evaluate its potential in acting as a bone graft substitute for critical-sized bone defects. In vitro results indicated there was a major improvement in biological response, including cell attachment, proliferation and alkaline phosphatase expression for osteoblast-like cells when seeded on the composite material compared to unmodified polyurethane. In vivo evaluation on a critical-sized defect model of New Zealand White (NZW) rabbit indicated there was bone ingrowth along the defect area with the introduction of the new filler. A tight interface formed between bone and filler, with osteogenic cells proliferating on the surface. The result suggested polyurethane/poly l-lactic acid composite is a material with the potential to act as a bone graft substitute for orthopedics application.
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Affiliation(s)
- Yuk Fai Lui
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China.
| | - Wing Yuk Ip
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China.
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Induced membrane technique: Advances in the management of bone defects. Int J Surg 2017; 42:110-116. [DOI: 10.1016/j.ijsu.2017.04.064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/19/2017] [Accepted: 04/30/2017] [Indexed: 12/31/2022]
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Abstract
Although bone defects after trauma appear in different locations and forms, many clinicians have adopted a single strategy to deal with any defect. In this overview, a distinction is made between metaphyseal, or cancellous defects, and diaphyseal, or cortical defects. The treatment goals and background of these two types of defects are discussed in order to describe the difference in strategy and hence the difference in treatment method.
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Affiliation(s)
- Taco J Blokhuis
- Department of Surgery, Maastricht University Medical Center +, Postbus 5800, 6202 AZ Maastricht, The Netherlands.
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Morris R, Hossain M, Evans A, Pallister I. Induced membrane technique for treating tibial defects gives mixed results. Bone Joint J 2017; 99-B:680-685. [PMID: 28455479 DOI: 10.1302/0301-620x.99b5.bjj-2016-0694.r2] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/29/2016] [Indexed: 02/07/2023]
Abstract
Aims This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients. Patients and Methods This retrospective case series reviewed 12 patients treated between 2010 and 2015 to determine their clinical outcome. Patients were mostly male with a mean age of 36 years (16 to 62). The outcomes recorded included union, infection and amputation. The mean follow-up was 675 days (403 to 952). Results The mean tibial defect measured 5.8 cm (2 to 15) in length. Of the 12 patients, 11 had an open fracture. Eight underwent fixation with an intramedullary nail, three with plates and one with a Taylor Spatial Frame. The mean interval between stages was 57 days (35 to 89). Bony union was achieved in only five patients. Five patients experienced infective complications during treatment, with two requiring amputation because of severe infection. Conclusion The Masquelet technique was relatively ineffective in achieving union in this series, and was associated with a high rate of infection. Cite this article: Bone Joint J 2017;99-B:680–5.
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Affiliation(s)
- R. Morris
- University Hospital of Wales, Heath
Park, Cardiff, CF14 4XW, UK
| | - M. Hossain
- Princess Royal University Hospital, King’s
College Hospital NHS Foundation Trust, BR6
8ND, UK
| | - A. Evans
- West Wales General Hospital, Dolgwili
Road, Carmarthen, SA31
2AF, UK
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Dilogo IH, Primaputra MRA, Pawitan JA, Liem IK. Modified Masquelet technique using allogeneic umbilical cord-derived mesenchymal stem cells for infected non-union femoral shaft fracture with a 12 cm bone defect: A case report. Int J Surg Case Rep 2017; 34:11-16. [PMID: 28324799 PMCID: PMC5358950 DOI: 10.1016/j.ijscr.2017.03.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/01/2017] [Accepted: 03/03/2017] [Indexed: 01/15/2023] Open
Abstract
A case of infected non-union fracture with critical-sized bone defect. Modified Masquelet technique was used to overcome the defect. The addition of allogenic UC-MSCs, BMP-2 and hydroxyapatite encourages healing. This technique may serve as an effective way to overcome large defects.
Introduction Non-union due to large bone loss often causes significant long-term morbidity. We incorporate the use of allogeneic umbilical cord-derived mesenchymal stem cells (UC-MSCs) as part of the diamond concept of regenerative medicine in a case of infected non-union fracture. Presentation of case We reported a 54-year-old female patient presenting with pain on the right thigh. She was previously diagnosed with a closed fracture of the right femoral shaft and underwent four surgeries before finally being referred to Dr. Cipto Mangunkusumo General Hospital with infected non-union of the right femoral shaft. The patient was treated with a combination of UC-MSCs, bone morphogenetic protein-2 (BMP-2), Hydroxyapatite (HA), and mechanical stabilization using Masquelet Technique. The combination of allogeneic MSCs, BMP2, HA, and Masquelet Technique was successful in creating new bone with no apparent side effects. Discussion Bone loss might be caused by external factors (true defects), or structural loss of the existing bone. The combination of allogeneic UC-MSCs, BMP-2, HA and an induced membrane technique pioneered by Masquelet allowed for faster regeneration process and more optimal bone healing. This paper aims to assess and compare the result of such procedures with the previous four surgeries done to the patient, which did not yield satisfactory results. Conclusion The application of allogeneic UC-MSC, BMP-2, HA and Masquelet technique as proposed in the diamond concept is a viable method in treating critical-sized bone defect and provides an effective way to overcome non-union caused by large defect.
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Affiliation(s)
- Ismail Hadisoebroto Dilogo
- Consultant of Orthopaedic Trauma and Reconstruction, Department of Orthopaedic and Traumatology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; Stem Cell Medical Technology, Integrated Service Unit, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; Stem Cell and Tissue Engineering Research Center, Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.
| | - Muhammad Rizqi Adhi Primaputra
- Resident of Orthopaedic Surgery, Department of Orthopaedic and Traumatology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Jeanne Adiwinata Pawitan
- Department of Histology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; Stem Cell Medical Technology, Integrated Service Unit, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; Stem Cell and Tissue Engineering Research Center, Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Isabella Kurnia Liem
- Stem Cell Medical Technology, Integrated Service Unit, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; Department of Anatomy, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia; Stem Cell and Tissue Engineering Research Center, Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Two stage management of Cierny-Mader type IV chronic osteomyelitis of the long bones. Injury 2017; 48:511-518. [PMID: 28088375 DOI: 10.1016/j.injury.2017.01.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/15/2016] [Accepted: 01/01/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cierny-Mader (C-M) type IV chronic osteomyelitis represents a complex clinical challenge with permeation of extensive bone and soft tissue involvement. Aggressive debridement through viable tissue margin includes en bloc resection improves the odds of eradication of infection, which creates large bone and soft tissue loss in treating this type of osteomyelitis. The potentially large defects increase reconstruction problems with traditional reconstruction technique. The newly staged induced membrane technique presents length-independent, potential as an alternative reconstruction method for segmental bone defects due to type IV chronic osteomyelitis. The purpose of this study was to assess the result and related factors of C-M type IV chronic osteomyelitis treated with staged methods of aggressive debridement and induced membrane technique. METHODS From January 2012 to January 2014, 36 consecutive adult patients of C-M type IV chronic osteomyelitis were treated by this staged method in our clinical center with a minimum of 2-years follow-up. The clinical and imaging results were retrospectively analyzed. RESULTS Five patients had a second debridement and eight needed a local flap transfer to cover the wound in the first stage. Patients formed a mean of 5.5cm (range: 2-10.9) segmental bone defect; Sixteen patients had autograft and twenty had autograft mixed allograft in the second stage. The mean follow-up time was 29.5 months (range: 24-45). No patients required amputation. Bone union was achieved in all patients. Clinical eradication of osteomyelitis was achieved in 35 (97%) patients, 35 (97%) patients were able to walk independently, and 31patients (86%) returned to work. Patients returned to a mean of 82% (46.3%-100%) lower extremity function. Bone union time was not dependent on the length of bone defect, but associated with the infection site (p=0.005) and age (p=0.005). CONCLUSIONS Staged methods of aggressive debridement and induced membrane technique seems to be a simple, reliable and effective for the treatment of C-M type IV chronic osteomyelitis. Advanced age and poor soft tissue envelope may have adverse affects and are relative contraindications. The combined assessment and management of such patients with a plastic surgeon are advocated.
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Aurégan JC, Bégué T, Rigoulot G, Glorion C, Pannier S. Success rate and risk factors of failure of the induced membrane technique in children: a systematic review. Injury 2016; 47 Suppl 6:S62-S67. [PMID: 28040089 DOI: 10.1016/s0020-1383(16)30841-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The induced membrane technique was designed by Masquelet et al. to address segmental bone defects of critical size in adults. It has been used after bone defects of traumatic, infectious and tumoral origin with satisfactory results. Recently, it has been used in children but, after an initial enthusiasm, several cases of failure have been reported. The purpose of this study was to assess the success rate and the risk factors of failure of the induced membrane for children. We conducted a systematic review of all the studies reporting the results of the induced membrane technique to address bone defects of critical size in children. Our primary outcome was the success rate of the technique defined as a bone union before any iterative surgery. Our secondary outcomes were the complications and the risk factors of failure. We searched Medline via Pubmed, EMBASE and the Cochrane Library. Twelve studies, including 69 patients, met the inclusion criteria. There were 41 boys and 28 girls. Mean age at surgery was 10 years. Mean size of resection was 12.38 cm and the mean time between the two stages was 5.86 months. Mean rate of bone union after the two stages of the induced membrane technique was 58% (40/69) but this rate increased to 87% after revision surgeries (60/69). Main complications were non-unions (19/69), lysis of the graft (6/69) and fractures of the bone graft (6/69). Only 1/69 deep infection was reported. Other non specific complications were regularly reported such limb length discrepancies, joint stiffness and protruding wires. Risk factor of failure that could be suspected comprised the resection of a malignant tumour, a bone defect located at the femur, a wide resection, a long time between the two stages, an unstable osteosynthesis and a bone graft associating autograft to other graft materials. The induced membrane technique is suitable for bone defects of critical size in children. It is a reliable technique with no need of micro vascular surgery. However, we found several risk factors of failure for the use of the induced membrane technique to address segmental bone defect of critical size in children.
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Affiliation(s)
- Jean-Charles Aurégan
- Department of Orthopaedic Surgery and Traumatology, Antoine Béclère Hospital, AP-HP, University Paris Sud, 157 rue de la Porte de Trivaux, 92140, Clamart, France.
| | - Thierry Bégué
- Department of Orthopaedic Surgery and Traumatology, Antoine Béclère Hospital, AP-HP, University Paris Sud, 157 rue de la Porte de Trivaux, 92140, Clamart, France
| | - Guillaume Rigoulot
- Department of Orthopaedic Paediatrics, Necker - Enfants Malades Hospital, AP-HP, University Paris-Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Christophe Glorion
- Department of Orthopaedic Paediatrics, Necker - Enfants Malades Hospital, AP-HP, University Paris-Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Stéphanie Pannier
- Department of Orthopaedic Paediatrics, Necker - Enfants Malades Hospital, AP-HP, University Paris-Descartes, 149 rue de Sèvres, 75015, Paris, France
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