1
|
Wu JH, Bao QW, Wang SK, Zhou PY, Xu SG. Mechanisms of the Masquelet technique to promote bone defect repair and its influencing factors. Chin J Traumatol 2024:S1008-1275(24)00054-3. [PMID: 38734563 DOI: 10.1016/j.cjtee.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/21/2024] [Accepted: 04/02/2024] [Indexed: 05/13/2024] Open
Abstract
The Masquelet technique, also known as the induced membrane technique, is a surgical technique for repairing large bone defects based on the use of a membrane generated by a foreign body reaction for bone grafting. This technique is not only simple to perform, with few complications and quick recovery, but also has excellent clinical results. To better understand the mechanisms by which this technique promotes bone defect repair and the factors that require special attention in practice, we examined and summarized the relevant research advances in this technique by searching, reading, and analysing the literature. Literature show that the Masquelet technique may promote the repair of bone defects through the physical septum and molecular barrier, vascular network, enrichment of mesenchymal stem cells, and high expression of bone-related growth factors, and the repair process is affected by the properties of spacers, the timing of bone graft, mechanical environment, intramembrane filling materials, artificial membrane, and pharmaceutical/biological agents/physical stimulation.
Collapse
Affiliation(s)
- Jiang-Hong Wu
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China; Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Quan-Wei Bao
- Trauma Center, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Shao-Kang Wang
- Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Pan-Yu Zhou
- Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Shuo-Gui Xu
- Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
| |
Collapse
|
2
|
Astudillo Potes MD, Mitra I, Hanson K, Camilleri ET, Gaihre B, Shafi M, Hamouda A, Lu L, Elder BD. Biodegradable poly(caprolactone fumarate) 3D printed scaffolds for segmental bone defects within the Masquelet technique. J Orthop Res 2024. [PMID: 38522018 DOI: 10.1002/jor.25839] [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] [Received: 12/05/2023] [Revised: 02/21/2024] [Accepted: 03/08/2024] [Indexed: 03/25/2024]
Abstract
Segmental bone defects, often clinically treated with nondegradable poly(methylmethacrylate) (PMMA) in multistage surgeries, present a significant clinical challenge. Our study investigated the efficacy of 3D printed biodegradable polycaprolactone fumarate (PCLF)/PCL spacers in a one-stage surgical intervention for these defects, focusing on early bone regeneration influenced by spacer porosities. We compared nonporous PCLF/PCL and PMMA spacers, conventionally molded into cylinders, with porous PCLF/PCL spacers, 3D printed to structurally mimic segmental defects in rat femurs for a 4-week implantation study. Histological analysis, including tissue staining and immunohistochemistry with bone-specific antibodies, was conducted for histomorphometry evaluation. The PCLF/PCL spacers demonstrated compressive properties within 6 ± 0.5 MPa (strength) and 140 ± 15 MPa (modulus). Both porous PCLF/PCL and Nonporous PMMA formed collagen-rich membranes (PCLF/PCL: 92% ± 1.3%, PMMA: 86% ± 1.5%) similar to those induced in the Masquelet technique, indicating PCLF/PCL's potential for one-stage healing. Immunohistochemistry confirmed biomarkers for tissue regeneration, underscoring PCLF/PCL's regenerative capabilities. This research highlights PCLF/PCL scaffolds' ability to induce membrane formation in critical-sized segmental bone defects, supporting their use in one-stage surgery. Both solid and porous PCLF/PCL spacers showed adequate compressive properties, with the porous variants exhibiting BMP-2 expression and woven bone formation, akin to clinical standard PMMA. Notably, the early ossification of the membrane into the pores of porous scaffolds suggests potential for bone interlocking and regeneration, potentially eliminating the need for a second surgery required for PMMA spacers. The biocompatibility and biodegradability of PCLF/PCL make them promising alternatives for treating critical bone defects, especially in vulnerable patient groups.
Collapse
Affiliation(s)
- Maria D Astudillo Potes
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Indranath Mitra
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kari Hanson
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Emily T Camilleri
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bipin Gaihre
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mahnoor Shafi
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Lichun Lu
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin D Elder
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
3
|
Saab M, Zobrist C, Blanchemain N, Martel B, Chai F. Systematic literature review of in vivo rat femoral defect models using biomaterials to improve the induced membrane technique: a comprehensive analysis. EFORT Open Rev 2024; 9:138-145. [PMID: 38320402 PMCID: PMC10873241 DOI: 10.1530/eor-23-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Purpose The aim of this study was to conduct a systematic literature review analyzing the results of in vivo rat femoral defect models using biomaterials for improving the induced membrane technique (IMT). Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Embase, and Web of Science databases were searched. Inclusion criteria were studies reporting results of the IMT in in vivo rat femoral critical-sized defect models using a biomaterial possibly combined with molecules. Methodologic quality was assessed with the Animal Research: Reporting In Vivo Experiments guidelines. Results Twenty studies met the inclusion criteria. Femoral stabilization with plate and screws was the most frequent. Histologic, biomechanical, and/or radiologic analyses were performed. In two-stage strategies, the PMMA spacer could be associated with bioactive molecules to enhance IM growth factor expression and improve bone formation. Modulating the roughness of spacers could increase IM thickness and accelerate its formation. In one-stage strategies, human tissue-derived membranes combined with bone grafting achieved bone formation comparable to a standard IMT. All calcium phosphate grafts seemed to require a functionalization with growth factors or bone marrow mononuclear cells to improve outcomes compared with non-functionalized grafts. Conclusion This systematic review described the main parameters of the in vivo rat femoral defect models using biomaterials to improve the induced membrane technique. Although the studies included had several methodological limitations that may limit the scope of these conclusions, one- and two-stage strategies reported promising results with biomaterials to improve the IMT.
Collapse
Affiliation(s)
- Marc Saab
- CHU Lille, Orthopaedic and Traumatology Department, Hôpital Roger Salengro, Lille, France
- University of Lille, INSERM, CHU Lille, U1008 – Advanced Drug Delivery Systems and Biomaterials, Lille, France
| | - Cédric Zobrist
- University of Lille, CNRS, INRAE, Centrale Lille, UMR 8207 – UMET – Unité Matériaux et Transformations, Lille, France
| | - Nicolas Blanchemain
- University of Lille, INSERM, CHU Lille, U1008 – Advanced Drug Delivery Systems and Biomaterials, Lille, France
| | - Bernard Martel
- University of Lille, CNRS, INRAE, Centrale Lille, UMR 8207 – UMET – Unité Matériaux et Transformations, Lille, France
| | - Feng Chai
- University of Lille, INSERM, CHU Lille, U1008 – Advanced Drug Delivery Systems and Biomaterials, Lille, France
| |
Collapse
|
4
|
Kalantar SH, Saffar H, Hoveidaei AH. Bone reconstruction with modified Masquelet technique in open distal femoral fractures: a case series. BMC Musculoskelet Disord 2024; 25:26. [PMID: 38167118 PMCID: PMC10759597 DOI: 10.1186/s12891-023-07091-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Large bone defects require complex treatment, multidisciplinary resources, and expert input, with surgical procedures ranging from reconstruction and salvage to amputation. The aim of this study was to provide the results of a case series of open comminuted intra-articular distal femoral fractures with significant bone loss that were managed by early fixation using anatomical plates and a modified Masquelet technique with the addition of surgical propylene mesh. METHODS This retrospective study included all patients referred to our institution with OTA/AO C3 distal femur open fractures and meta-diaphyseal large bone loss between April 2019 and February 2021. We treated the fractures with irrigation and debridement, acute primary screw and plate fixation in the second look operation, and Masquelet method using shell-shaped antibiotic beads supplemented by propylene surgical mesh to keep the cements in place. The second step of the procedure was conducted six to eight weeks later with bone grafting and mesh augmentation to contain bone grafts. Surprisingly, hard callus formation was observed in all patients at the time of the second stage of Masquelet procedure. RESULTS All five patients' articular and meta-diaphyseal fractures with bone loss healed without major complications. The average union time was 159 days. The mean knee range of motion was 5-95 degrees. The average Lower Extremity Functional Score (LEFS) was 49 out of 80. CONCLUSIONS Combination of early plate fixation and the modified Masquelet technique with polypropylene mesh is an effective method for managing large bone defects in open intra-articular distal femoral fractures with bone loss, resulting in shorter union time possibly associated with the callus formation process. This technique may also be applicable to the management of other similar fractures specially in low-income and developing areas.
Collapse
Affiliation(s)
- Seyed Hadi Kalantar
- Joint Reconstruction Research Center, IKHC, Tehran University of Medical Science, Tehran, Iran
| | - Hana Saffar
- Cancer Institute, IKHC, Tehran University of Medical Science, Tehran, Iran
| | - Amir Human Hoveidaei
- Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
5
|
Siverino C, Vanvelk N, Nehrbass D, Mischler D, Geoff Richards R, Morgenstern M, Zeiter S, Arens D, Fintan Moriarty T. Comparative bone healing with induced membrane technique (IMT) versus empty defects in septic and aseptic conditions in a novel rabbit humerus model. BMC Musculoskelet Disord 2023; 24:886. [PMID: 37964215 PMCID: PMC10644571 DOI: 10.1186/s12891-023-07031-3] [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: 05/11/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Long bone defects resulting from primary trauma or secondary to debridement of fracture-related infection (FRI) remain a major clinical challenge. One approach often used is the induced membrane technique (IMT). The effectiveness of the IMT in infected versus non-infected settings remains to be definitively established. In this study we present a new rabbit humerus model and compare the IMT approach between animals with prior infection and non-infected equivalents. METHODS A 5 mm defect was created in the humerus of New Zealand White rabbits (n = 53) and fixed with a 2.5 mm stainless steel plate. In the non-infected groups, the defect was either left empty (n = 6) or treated using the IMT procedure (PMMA spacer for 3 weeks, n = 6). Additionally, both approaches were applied in animals that were inoculated with Staphylococcus aureus 4 weeks prior to defect creation (n = 5 and n = 6, respectively). At the first and second revision surgeries, infected and necrotic tissues were debrided and processed for bacteriological quantification. In the IMT groups, the PMMA spacer was removed 3 weeks post implantation and replaced with a beta-tricalcium phosphate scaffold and bone healing observed for a further 10 weeks. Infected groups also received systemic antibiotic therapy. The differences in bone healing between the groups were evaluated radiographically using a modification of the radiographic union score for tibial fractures (RUST) and by semiquantitative histopathology on Giemsa-Eosin-stained sections. RESULTS The presence of S. aureus infection at revision surgery was required for inclusion to the second stage. At the second revision surgery all collected samples were culture negative confirming successful treatment. In the empty defect group, bone healing was increased in the previously infected animals compared with non-infected controls as revealed by radiography with significantly higher RUST values at 6 weeks (p = 0.0281) and at the end of the study (p = 0.0411) and by histopathology with increased cortical bridging (80% and 100% in cis and trans cortical bridging in infected animals compared to 17% and 67% in the non-infected animals). With the IMT approach, both infected and non-infected animals had positive healing assessments. CONCLUSION We successfully developed an in vivo model of bone defect healing with IMT with and without infection. Bone defects can heal after an infection with even better outcomes compared to the non-infected setting, although in both cases, the IMT achieved better healing.
Collapse
Affiliation(s)
- Claudia Siverino
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland
| | - Niels Vanvelk
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland
| | - Dirk Nehrbass
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland
| | - Dominic Mischler
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland
| | | | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Stephan Zeiter
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland
| | - Daniel Arens
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland
| | - Thomas Fintan Moriarty
- AO Research Institute Davos, Clavadelerstrasse 1, Davos-Platz, 7270, Switzerland.
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.
| |
Collapse
|
6
|
Yin Q, Chen X, Dai B, Liu J, Yang Y, Song S, Ding Y. Varying degrees of spontaneous osteogenesis of Masquelet's induced membrane: experimental and clinical observations. BMC Musculoskelet Disord 2023; 24:384. [PMID: 37189083 PMCID: PMC10184391 DOI: 10.1186/s12891-023-06498-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/05/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Masquelet's induced membrane (IM) has osteogenesis activity, but IM spontaneous osteogenesis (SO) has not been described previously. OBJECTIVES To report on varying degrees of IMSO and analyze its possible causes. METHODS Twelve eight-week-old male Sprague-Dawley rats with 10 mm right femoral bone defects who received the first stage of IM technique (IMT) were used to observe the SO. In addition, clinical data from patients with bone defects who received the first stage of IMT with an interval of > 2 months post-operatively and exhibited SO between January 2012 and June 2020 were retrospectively analyzed. The SO was divided into four grades according to the amount and characteristics of the new bone formation. RESULTS At twelve weeks, grade II SO was observed in all rats, and more new bone was formed in the IM near the bone end forming an uneven margin. Histology revealed bone and cartilage foci in the new bone. Four of the 98 patients treated with the first stage of IMT exhibited IMSO, including one female and three males with a median age of 40.5 years (range 29-52 years). The bone defects were caused by severe fractures and infection in two cases and by infection or tumor in one case each. Partial or segmental defects occurred in two cases. The time interval between inserting a cement spacer and diagnosis of SO ranged from six months to nine years. Two cases were grade I, and one case each of grades III and IV. CONCLUSION Varying degrees of SO confirm the existence of the IMSO phenomenon. Bioactive bone tissue or local inflammation and a long time interval are the primary reasons underlying enhancement of the osteogenic activity of IM and leading to SO, which tends to take place as endochondral osteogenesis.
Collapse
Affiliation(s)
- Qudong Yin
- Department of Orthopaedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China.
| | - Xueming Chen
- Department of Orthopaedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China
| | - Beichen Dai
- Department of Orthopaedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China
| | - Jun Liu
- Department of Orthopaedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China
| | - Ying Yang
- Department of Radiology, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China
| | - Sheng Song
- Department of Orthopaedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China.
| | - Yanping Ding
- Department of Radiology, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214062, China.
| |
Collapse
|
7
|
Liodakis E, Pacha TO, Aktas G, Sehmisch S, Mommsen P. [Biological reconstruction of large bone defects : Masquelet technique and new procedures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:184-189. [PMID: 36573997 DOI: 10.1007/s00113-022-01267-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 12/28/2022]
Abstract
Extensive diaphyseal and metaphyseal bone defects continue to pose a major challenge for orthopedic trauma surgeons. Various treatment options have been described for the biological reconstruction of these defects. The most frequently used methods are bone segment transport, the Masquelet technique and 3D printed scaffolds. As far as the Masquelet technique is concerned, in the first stage spacers, such as polymethyl methacrylate (PMMA), calcium sulfate or polypropylene are inserted into the bone defects to induce a foreign body membrane. In the second stage the bone defect surrounded by the induced membrane is filled with autologous cancellous bone. The time interval between the first and second interventions is usually 4-8 weeks whereby the induced membranes do not lose their bioactivity even with a latency period longer than 8 weeks. Three-dimensional printed scaffolds are increasingly used but large clinical studies are lacking in order to show the exact role of this procedure in the reconstruction of bone defects.
Collapse
Affiliation(s)
- Emmanouil Liodakis
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Tarek Omar Pacha
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Gökmen Aktas
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Stephan Sehmisch
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Philipp Mommsen
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| |
Collapse
|
8
|
Lu W, Zhao R, Fan X, Wang H, Zeng M. Time-varying characteristics of the induced membrane and its effects on bone defect repair. Injury 2023; 54:318-328. [PMID: 36581479 DOI: 10.1016/j.injury.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/17/2022] [Accepted: 12/23/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE This study intended to determine the properties of induced membranes after various periods of polymethyl methacrylate (PMMA) retention and the effect of different retention intervals on subsequent defect repair. METHODS Model of a critical bone defect in rabbits was prepared to obtain the induced membrane. For varying intervals of spacer insertion (2, 4, 6, 8, 12, 16, and 20 weeks postoperatively), angiogenesis, osteogenesis, and MSC-related properties were analyzed by immunohistochemistry and western-blot. Furthermore, 2, 4, 6, and 8 weeks after PMMA insertion, bone grafting was performed. Characteristics of defect repair were analyzed by X-ray and micro-CT analysis. RESULTS The induced membrane displayed angiogenesis, osteogenesis, and MSC-related properties from the 2- to 20-week intervals. Quantitation of protein expression (RUNX2, ALP, VEGF, TGF-beta, OCT4, and STRO1) revealed that selected proteins gradually rose to a high level at 4-8 weeks postoperatively and then decreased to a low level over a long time period. Following bone grafting, the most new bone formation was in the group when grafting was performed at 4 weeks, followed by the groups at 2 and 6 weeks, with the least in the group at 8 weeks. CONCLUSION The induced membrane displays angiogenesis, osteogenesis, and MSC-related properties from the 2- to 20-week intervals. These were increased to a peak level at 4-8 weeks postoperatively and then gradually decreased. The optimal timing for bone grafting at the second stage in the presented model was 4 weeks after PMMA insertion.
Collapse
Affiliation(s)
- Wei Lu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Ruibo Zhao
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Xiaolei Fan
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Haoyi Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Min Zeng
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China.
| |
Collapse
|
9
|
Durand M, Oger M, Nikovics K, Venant J, Guillope AC, Jouve E, Barbier L, Bégot L, Poirier F, Rousseau C, Pitois O, Mathieu L, Favier AL, Lutomski D, Collombet JM. Influence of the Immune Microenvironment Provided by Implanted Biomaterials on the Biological Properties of Masquelet-Induced Membranes in Rats: Metakaolin as an Alternative Spacer. Biomedicines 2022; 10:biomedicines10123017. [PMID: 36551773 PMCID: PMC9776074 DOI: 10.3390/biomedicines10123017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Macrophages play a key role in the inflammatory phase of wound repair and foreign body reactions-two important processes in the Masquelet-induced membrane technique for extremity reconstruction. The macrophage response depends largely on the nature of the biomaterials implanted. However, little is known about the influence of the macrophage microenvironment on the osteogenic properties of the induced membrane or subsequent bone regeneration. We used metakaolin, an immunogenic material, as an alternative spacer to standard polymethylmethacrylate (PMMA) in a Masquelet model in rats. Four weeks after implantation, the PMMA- and metakaolin-induced membranes were harvested, and their osteogenic properties and macrophage microenvironments were investigated by histology, immunohistochemistry, mass spectroscopy and gene expression analysis. The metakaolin spacer induced membranes with higher levels of two potent pro-osteogenic factors, transforming growth factor-β (TGF-β) and bone morphogenic protein-2 (BMP-2). These alternative membranes thus had greater osteogenic activity, which was accompanied by a significant expansion of the total macrophage population, including both the M1-like and M2-like subtypes. Microcomputed tomographic analysis showed that metakaolin-induced membranes supported bone regeneration more effectively than PMMA-induced membranes through better callus properties (+58%), although this difference was not significant. This study provides the first evidence of the influence of the immune microenvironment on the osteogenic properties of the induced membranes.
Collapse
Affiliation(s)
- Marjorie Durand
- Osteo-Articulary Biotherapy Unit, Department of Medical and Surgical Assistance to the Armed Forces, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
- Correspondence:
| | - Myriam Oger
- Imaging Unit, Department of Platforms and Technology Research, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Krisztina Nikovics
- Imaging Unit, Department of Platforms and Technology Research, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Julien Venant
- Osteo-Articulary Biotherapy Unit, Department of Medical and Surgical Assistance to the Armed Forces, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
- Tissue Engineering Research Unit-URIT, Sorbonne Paris Nord University, 93000 Bobigny, France
| | - Anne-Cecile Guillope
- Osteo-Articulary Biotherapy Unit, Department of Medical and Surgical Assistance to the Armed Forces, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Eugénie Jouve
- Osteo-Articulary Biotherapy Unit, Department of Medical and Surgical Assistance to the Armed Forces, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Laure Barbier
- Molecular Biology Unit, Department of Platforms and Technology Research, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Laurent Bégot
- Imaging Unit, Department of Platforms and Technology Research, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Florence Poirier
- Tissue Engineering Research Unit-URIT, Sorbonne Paris Nord University, 93000 Bobigny, France
| | - Catherine Rousseau
- Molecular Biology Unit, Department of Platforms and Technology Research, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Olivier Pitois
- Laboratoire Navier, Gustave Eiffel University, Ecole des Ponts ParisTech, CNRS, 77447 Marne-la-Vallée, France
| | - Laurent Mathieu
- Osteo-Articulary Biotherapy Unit, Department of Medical and Surgical Assistance to the Armed Forces, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
- Department of Surgery, Ecole du Val-de-Grace, French Military Health Service Academy, 1 Place Alphonse Laveran, 75005 Paris, France
| | - Anne-Laure Favier
- Imaging Unit, Department of Platforms and Technology Research, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| | - Didier Lutomski
- Tissue Engineering Research Unit-URIT, Sorbonne Paris Nord University, 93000 Bobigny, France
| | - Jean-Marc Collombet
- Osteo-Articulary Biotherapy Unit, Department of Medical and Surgical Assistance to the Armed Forces, French Armed Forces Biomedical Research Institute, 91223 Brétigny-sur-Orge, France
| |
Collapse
|
10
|
Yao J, Zeng Y, Yang J, Wu Q, Chen L, Zheng L, Wang R, Zhu H, Cui H, Huang Y, Cheng S. Repairing tendon-exposed wounds by combing the Masquelet technique with dermoplasty. Front Surg 2022; 9:995316. [PMID: 36451681 PMCID: PMC9704049 DOI: 10.3389/fsurg.2022.995316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/10/2022] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Wound repair is a new field that has emerged in China in the last 5 years. Exposed tendon wounds are one of the most common problems faced in wound treatment today, as the poor blood supply leads to low survival rates of skin grafts. This paper explores the feasibility of applying the Masquelet technique to repair tendon-exposed wounds. METHOD We examined 12 patients with tendon-exposed wounds, 5 males and 7 females, from January 2021 to November 2021, including 2 patients with post-traumatic wounds, 8 diabetic patients with dorsal wounds, and 2 patients with various chronic infections. The Masquelet technique was employed to treat these wounds. The wound surface was sealed with antibiotic bone cement to form an induction membrane, the cement was removed after 3-4 weeks, and the wound was repaired with skin grafts to observe survival, appearance, texture, healing, and related functions. RESULTS All wounds were covered with antibiotic bone cement, and after 3-4 weeks, an induction membrane was applied, and in 10 out of 12 patients, full-thickness skin grafts were applied, and the patients survived. However, in 2 patients, the skin became partially necrotic, but these patients recovered by changing medications. CONCLUSION The current study found that direct skin grafting may effectively treat exposed tendon wounds once the Masquelet approach generates the induction membrane. Further, this method is less difficult, less expensive, and easier to care for the procedure that deserves to be used more frequently.
Collapse
Affiliation(s)
- Jiangling Yao
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Yunfu Zeng
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Jian Yang
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Qian Wu
- Academy of Pediatrics, Hainan Medical University, Haikou, China
| | - Liying Chen
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Linyang Zheng
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Rong Wang
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Hengjie Zhu
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Hongwang Cui
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| | - Yuesheng Huang
- Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology School of Medicine; Department of Wound Repair, Southern University of Science and Technology Hospital, Shenzhen, China
| | - Shaowen Cheng
- Emergency and Traumatology Department, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, China
- Key Laboratory of Emergency and Trauma Ministry of Education, Hainan Medical University, Haikou, China
| |
Collapse
|
11
|
Masquelet technique in military practice: specificities and future directions for combat-related bone defect reconstruction. Mil Med Res 2022; 9:48. [PMID: 36050805 PMCID: PMC9438145 DOI: 10.1186/s40779-022-00411-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022] Open
Abstract
Because of its simplicity, reliability, and replicability, the Masquelet induced membrane technique (IMT) has become one of the preferred methods for critical bone defect reconstruction in extremities. Although it is now used worldwide, few studies have been published about IMT in military practice. Bone reconstruction is particularly challenging in this context of care due to extensive soft-tissue injury, early wound infection, and even delayed management in austere conditions. Based on our clinical expertise, recent research, and a literature analysis, this narrative review provides an overview of the IMT application to combat-related bone defects. It presents technical specificities and future developments aiming to optimize IMT outcomes, including for the management of massive multi-tissue defects or bone reconstruction performed in the field with limited resources.
Collapse
|
12
|
Liodakis E, Giannoudis VP, Sehmisch S, Jha A, Giannoudis PV. Bone defect treatment: does the type and properties of the spacer affect the induction of Masquelet membrane? Evidence today. Eur J Trauma Emerg Surg 2022; 48:4403-4424. [PMID: 35726029 DOI: 10.1007/s00068-022-02005-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE High clinical success rates have been reported with the Masquelet technique in the treatment of traumatic bone loss. An increasing number of studies suggest that various factors can influence the properties of induced membranes. Goal of this systematic review is to answer the following questions: (1) which are the ideal spacer properties (material, surface topography, antibiotic supplementation) to booster the quality and osteogenic potential of induced membranes? (2) what is the ideal time to perform the second-stage operation? METHODS A systematic search using the keywords "((Masquelet) OR (Induced Periosteum)) AND ((Spacer) OR (Time))" was performed in PubMed, Embase and Cochrane Library according to PRISMA guidelines. Studies published up to the 23rd of February 2022 were included and assessed independently by two reviewers. RESULTS Thirteen animal and 1 clinical studies were identified to address the above questions. Spacer materials used were PMMA, silicone, titanium, polypropylene, PVA, PCL and calcium sulfate. With the exception of PVA sponges, all solid materials could induce membranes. Low union rates have been reported with titanium and rough surfaced spacers. Scraping of the inner surface of the IM also increased bony union rates. In terms of the ideal timing to perform the second-stage evidence suggests that membranes older than 8 weeks continue to have regenerative capacities similar to younger ones. CONCLUSION Membranes induced by smooth PMMA spacers loaded with low concentrations of antibiotics showed powerful osteogenic properties. Other materials such as Polypropylene or Calcium sulfate can also be used with good results. Despite current recommendation to perform the second stage operation in 4-8 weeks, membranes older than 8 weeks seem to have similar regenerative capacities to younger ones.
Collapse
Affiliation(s)
- Emmanouil Liodakis
- Trauma Department, Hannover Medical School (MHH), Carl-Neubergstr. 1, 30625, Hannover, Germany. .,Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, Leeds, UK.
| | - Vassilis P Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, Leeds, UK
| | - Stephan Sehmisch
- Trauma Department, Hannover Medical School (MHH), Carl-Neubergstr. 1, 30625, Hannover, Germany
| | - Animesh Jha
- School of Chemical and Process Engineering, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, University of Leeds, Leeds, UK
| |
Collapse
|
13
|
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.
Collapse
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.
| |
Collapse
|
14
|
Li S, Li Y, Jiang Z, Hu C, Gao Y, Zhou Q. Efficacy of total flavonoids of Rhizoma drynariae on the blood vessels and the bone graft in the induced membrane. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 99:153995. [PMID: 35278899 DOI: 10.1016/j.phymed.2022.153995] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Total flavonoids of Rhizoma drynariae (TFRD), a Chinese medicine, is widely used in the treatment of orthopedic diseases. However, there are few basic and clinical studies on the effect of TFRD on induced membrane technique (Masquelet technique). PURPOSE This trial is to explore effects of TFRD on vascularization of the induced membrane, and mineralization of the bone graft in rats with femoral bone defects. STUDY DESIGN AND METHODS Forty-eight Sprague-Dawley rats were randomly divided into high dose group (H-TFRD), medium dose group (M-TFRD), low dose group (L-TFRD) and control group (control). The segmental bone defects were established with 12 rats in per group. The polymethyl methacrylate (PMMA) spacer was implanted into the femoral bone defect of rats in the first-stage surgery. About 4 weeks after first-stage surgery, induced membranes of 6 rats in each group were selected. The blood vessels and angiogenesis-related factors in the induced membrane were analyzed by hematoxylin-eosin (HE) and masson staining, western blot, qPCR and immunohistostaining. The remaining rats in per group underwent second-stage surgery (bone grafting). Twelve weeks after the bone grafting, the bone tissues was examined by X-ray, micro-computed tomography (Micro-CT), HE staining and enzyme-linked immunosorbent assay (ELISA) to evaluate the growth of the bone graft. Meanwhile, the TFRD-containing serum was collected from rats to culture osteoblasts in vitro. Cell Counting Kit-8 (CCK-8) method, Alizarin Red S (ARS) staining, western blot and immunofluorescence were used to detect effects of TFRD on the osteoblasts' proliferation and BMP-SMAD signaling pathway. RESULTS Compared with the L-TFRD and control groups, the number of blood vessels and the expression of angiogenesis-related factors (VEGF, TGF-β1, BMP-2, PDGF-BB and CD31) were higher in the H-TFRD and M-TFRD groups. The Lane-Sandhu X-ray score, bone mass and growth rate of the bone graft in the H-TFRD and M-TFRD groups were significantly better than those in the L-TFRD and control groups. In addition, medium and high doses of TFRD significantly increased the expression of BMP-SMAD pathway proteins (BMP-2, SMAD1, SMAD4, SMAD5 and RUNX2) in rat serum and bone graft. In vitro, after osteoblasts were intervened with TFRD-containing serum from the H-TFRD and M-TFRD groups, the cell viability, the number of mineralized nodules and the phosphorylation of BMP-SMAD pathway proteins were markedly increased. CONCLUSION TFRD could promote the formation of blood vessels and the expression of angiogenesis-related factors during the formation of the induced membrane. During the growing period of bone graft, it could facilitate the growth and mineralization of bone graft in a dose-dependent manner, which is partly related to the activation and phosphorylation of BMP-SMAD signaling pathway.
Collapse
Affiliation(s)
- Shuyuan Li
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yue Li
- First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zexin Jiang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Cheng Hu
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ya Gao
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qishi Zhou
- First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China.
| |
Collapse
|
15
|
Stahl A, Park YB, Park SH, Lin S, Pan C, Kim S, Yang Y. Probing the role of methyl methacrylate release from spacer materials in induced membrane bone healing. J Orthop Res 2022; 40:1065-1074. [PMID: 34314063 PMCID: PMC8792109 DOI: 10.1002/jor.25147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/30/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023]
Abstract
In the induced membrane (IM) technique for bone reconstruction, a poly(methyl methacrylate) (PMMA) spacer is implanted to induce formation of a foreign body membrane around the defect site. Membrane development is essential for later bone grafting success, yet the mechanism by which the IM promotes bone regeneration remains unknown, as are the ways that spacer composition plays a role in the membrane's healing potential. This study investigated the impact of leached methyl methacrylate (MMA)-the major monomeric component of PMMA-on IM development. In vitro cell culture found that MMA elution did not impact endothelial cell or mesenchymal stem cell proliferation. For in vivo analysis, we advanced a streamlined rat femoral model to efficiently study the influence of spacer properties on IM characteristics. Comparison of membrane formation around polycaprolactone (PCL), MMA-eluting PCL (high-dose PCL-MMA and low-dose PCL-MMA), and surgical PMMA revealed robust membranes enveloped all groups after 4 weeks in vivo, with elevated expression of osteogenic bone morphogenetic protein-2 and angiogenic vascular endothelial growth factor compared with the surrounding muscle and bone tissues. Growth factor quantitation in IM tissue found no statistically significant difference between groups. New bone growth, vascularization, and CD163+ macrophage populations surrounding the polymer implants were also quantified; and blood vessel formation around high-dose PCL-MMA was found to be significantly decreased compared with PCL alone. To the best of our knowledge, these findings represent the first time that results have been obtained about the characteristics of membranes formed around PCL in the IM setting.
Collapse
Affiliation(s)
- A. Stahl
- Department of Orthopaedic Surgery, Stanford University, 240 Pasteur Drive, Stanford, CA 94304, USA,Department of Chemistry, Stanford University, 121 Mudd Building, CA 94305, USA
| | - YB. Park
- Department of Orthopaedic Surgery, Stanford University, 240 Pasteur Drive, Stanford, CA 94304, USA,Department of Prosthodontics, Yonsei University College of Dentistry, Seoul 120-752, Korea
| | - SH. Park
- Osong Research Institute, TaeWoong Medical Co., Ltd, 55-7, Osongsaengmyeong 2-ro, Korea
| | - S. Lin
- Department of Orthopaedic Surgery, Stanford University, 240 Pasteur Drive, Stanford, CA 94304, USA
| | - C.C. Pan
- Department of Orthopaedic Surgery, Stanford University, 240 Pasteur Drive, Stanford, CA 94304, USA,Department of Mechanical Engineering, Stanford University, 440 Escondido Mall, Stanford, CA94305, USA
| | - S. Kim
- Department of Orthopaedic Surgery, Stanford University, 240 Pasteur Drive, Stanford, CA 94304, USA
| | - Y.P. Yang
- Department of Orthopaedic Surgery, Stanford University, 240 Pasteur Drive, Stanford, CA 94304, USA,Department of Materials Science and Engineering, Stanford University, 496 Lomita Mall, Stanford, CA94305, USA,Department of Bioengineering, Stanford University, 443 Via Ortega, Stanford, CA94305, USA,Corresponding author: Yunzhi Peter Yang, Ph.D., Professor, Department of Orthopedic Surgery, School of Medicine, Stanford University, 240 Pasteur Drive, BMI 258, Stanford, CA 94304, Tel: 650-723-0772 (office), 650-725-8698 (Lab),
| |
Collapse
|
16
|
Masquelet technique: Effects of vancomycin concentration on quality of the induced membrane. Injury 2022; 53:868-877. [PMID: 34785083 DOI: 10.1016/j.injury.2021.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/22/2021] [Accepted: 11/02/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine the effects of polymethylmetnacrylate (PMMA) spacer loaded with different concentrations of vancomycin on the proliferative, osteogenic, and angiogenic capacity of the induced membrane. METHODS Varying concentrations of vancomycin (0, 1, 2, 4, 6, 8, and 10 g) were fully mixed with bone cement powder (40 g), resulting in seven experimental groups. Hollow cylindrical PMMA spacers (10 mm height, 3 mm external diameter, and 0.8 mm internal diameter) were formed by a mold and submerged in phosphate-buffered saline for antibiotic release by spectrophotometry. Eighty-four New Zealand white rabbits were evenly randomized into seven groups, and segmental radius shaft defects (10 mm) were created. Defects were filled with cylindrical PMMA spacers containing different vancomycin concentrations, and subsequently underwent intramedullary fixation with a retrograde Kirschner's wire. Tissue toxicity was assessed and the proliferative, osteogenic, and angiogenic capacity of induced membranes were qualitatively analyzed by immunohistochemistry and real-time PCR. RESULTS No obvious toxicity was observed in the animal model. Alizarin red s staining and qualitative detection of type I collagen, CD31, Ki67, and STRO-1 by immunohistochemistry revealed an obvious decrease in the percentage of positively stained cells and in osteogenic capacity when the concentration of vancomycin was more than 6 g per cement dose. Quantitation of gene expression related to osteogenesis (Col1a, Alp, and Runx2), vascularization (Vegf, Tgfb1, and vWF), and proliferation (Oct4 and Stro-1) by real-time PCR revealed slight increases in the expression of selected genes at low vancomycin concentrations (1-4 g per cement dose), and relatively lower gene expression when the concentration of vancomycin was more than 6 g per cement dose. CONCLUSION PMMA spacers loaded with relatively low concentrations of vancomycin (1-4 g per cement dose) did not interfere with the proliferative, osteogenic, and angiogenic capacity of induced membranes, and even promoted their capacity. In contrast, spacers loaded with relatively high concentrations of vancomycin (6-10 g per cement dose) had negative effects on osteoblast viability, angiogenesis, and proliferation.
Collapse
|
17
|
The induced membrane technique in animal models: a systematic review. OTA Int 2022; 5:e176. [PMID: 35282388 PMCID: PMC8900461 DOI: 10.1097/oi9.0000000000000176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/15/2021] [Indexed: 01/10/2023]
Abstract
Objectives: Data Sources: Study Selection: Data Extraction: Data Synthesis: Conclusions:
Collapse
|
18
|
Starks AO, Owen J, Isaacs J. Evaluation of the Induced Membrane for Neurotrophic Factors. J Hand Surg Am 2022; 47:130-136. [PMID: 34865951 DOI: 10.1016/j.jhsa.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/09/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Despite gaining popularity as a bridge for small and moderate nerve gaps, an acellular nerve allograft (ANA) lacks many of the neurotrophic characteristics of a nerve autograft. Pseudomembranes induced to form around temporary skeletal spacers are rich in growth factors. Induced membranes may have beneficial neurotrophic factors which could support ANA. METHODS Twenty-two male Sprague-Dawley rats underwent resection of 2 cm of the sciatic nerve. A silicone rod was inset in the defect of 11 experimental rats, and marking sutures only were placed in the nerve stumps of the remaining 11 control rats. After allowing 4 weeks for tissue maturation, tissue samples harvested from the induced membrane (experimental group) and the tissue bed (control group) were analyzed using Luminex multiplex assay to quantify differences in detectable levels of the following neurotrophic factors: nerve growth factor, glial-derived nerve factor, vascular endothelial growth factor, and transforming growth factor ß (TGF-ß) 1, 2, and 3, interleukin-1ß, and monocyte chemoattractant protein 1. RESULTS No difference was detected between the control and experimental groups in levels of vascular endothelial growth factor. Higher levels of TGF-ß1, TGF-ß2, TGF-ß3, glial-derived nerve factor, nerve growth factor, monocyte chemoattractant protein 1, and interleukin-1ß were detected in the experimental group. CONCLUSIONS In the setting of peripheral nerve injury, an induced membrane has higher levels of several neurotrophic factors that may support nerve regeneration compared to wound bed cicatrix. CLINICAL RELEVANCE This investigation provides impetus for further study examining the utility of using a staged induced membrane technique in conjunction with delayed nerve grafting in reconstruction of some peripheral nerve defects.
Collapse
Affiliation(s)
- Alexandria O Starks
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA.
| | - John Owen
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Jonathan Isaacs
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA
| |
Collapse
|
19
|
Takeuchi H, Ikeguchi R, Noguchi T, Ando M, Yoshimoto K, Sakamoto D, Matsuda S. The efficacy of combining a vascularized biogenic conduit and a decellularized nerve graft in the treatment of peripheral nerve defects: An experimental study using the rat sciatic nerve defect model. Microsurgery 2021; 42:254-264. [PMID: 34953149 DOI: 10.1002/micr.30853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/09/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although decellularized nerve grafts are often used as a bridging material in nerve defect repair, the lack of perfusion support in this procedure limits the regeneration capacity. To address this, we applied vascularized biogenic conduits, which are fibrous membranes prefabricated around the silicone rod that contain rich vascularity and macrophages, to nerve defect repair procedures using decellularized nerve grafts. The purpose of this study is to investigate the capacity of combining a vascularized biogenic conduit and a decellularized nerve graft for peripheral nerve regeneration using a 10-mm nerve defect model in rats. MATERIALS AND METHODS Sixteen adult male rats (F344 rats, 10-12 weeks, 200-250 g) were used in this study. For the prefabrication of vascularized biogenic conduits, a silicone rod was transplanted next to the sciatic nerve. After 8 weeks, this silicone rod was enveloped in connective tissue, called a vascularized biogenic conduit. The first rat was used to investigate the histological characteristics of vascularized biogenic conduits through immunofluorescence studies. The remaining 15 rats were divided into three groups to evaluate the efficacy of the combination of a decellularized nerve graft and a vascularized biogenic conduit: a decellularized nerve graft (DNG) group, a decellularized nerve graft with a vascularized biogenic conduit (DNG-w-VBC) group, and an autologous nerve graft (ANG) group. Eight weeks after nerve graft surgery, the assessment results of both functional recovery (electrophysical studies and target muscle atrophy) and morphological recovery (total number, diameter, and myelin thickness of the regenerated axons) of the regenerated nerves were examined. RESULTS Immunofluorescence studies revealed that the VBC contains extracellular matrix, vascular tissue, and macrophages. The results of the DNG-w-VBC group were superior to the DNG group in electrophysiological studies (CMAP; 6.29 ± 0.80% vs. 4.02 ± 3.35%, MNCV; 50.6 ± 8.4% vs. 25.7 ± 15.6%, p < .05, respectively), regenerated axon number (11,348 ± 812 vs. 7697 ± 2197, p < .05), and mean axon diameter (2.72 ± 0.33 μm vs. 1.64 ± 0.12 μm, p < .05). CONCLUSIONS Our study confirms that vascularized biogenic conduits supply vascularity and macrophages to nerve defect sites. Combining vascularized biogenic conduits with decellularized nerve grafts to treat nerve defects offers superior functional and morphological recovery of regenerated axons.
Collapse
Affiliation(s)
- Hisataka Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Noguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Maki Ando
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichi Yoshimoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Daichi Sakamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
20
|
Mathieu L, Murison JC, de Rousiers A, de l’Escalopier N, Lutomski D, Collombet JM, Durand M. The Masquelet Technique: Can Disposable Polypropylene Syringes be an Alternative to Standard PMMA Spacers? A Rat Bone Defect Model. Clin Orthop Relat Res 2021; 479:2737-2751. [PMID: 34406150 PMCID: PMC8726567 DOI: 10.1097/corr.0000000000001939] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Usually, the two-stage Masquelet induced-membrane technique for extremity reconstruction begins with a polymethylmethacrylate (PMMA) cement spacer-driven membrane, followed by an autologous cancellous bone graft implanted into the membrane cavity to promote healing of large bone defects. In exceptional cases, spacers made of polypropylene disposable syringes were successfully used instead of the usual PMMA spacers because of a PMMA cement shortage caused by a lack of resources. However, this approach lacks clinical evidence and requires experimental validation before being recommended as an alternative to the conventional technique. QUESTIONS/PURPOSES To (1) develop and (2) validate a critical-sized femoral defect model in rats for two stages of the Masquelet technique and to (3) compare the biological and bone healing properties of polypropylene-induced membranes and PMMA-induced membranes in this model. METHODS Fifty male Sprague Dawley rats aged 8 weeks old received a 6-mm femur defect, which was stabilized with an external fixator that was converted into an internal device. In the development phase, the defect was filled with PMMA in 16 rats to determine the most favorable timing for bone grafting. Two rats were excluded since they died of anesthetic complications. The other 14 were successively euthanized after 2 weeks (n = 3), 4 weeks (n = 4), 6 weeks (n = 4), and 8 weeks (n = 3) for induced membrane analyses. In the validation phase, 12 rats underwent both stages of the procedure using a PMMA spacer and were randomly assigned to two groups, whether the induced membrane was preserved or removed before grafting. To address our final objective, we implanted either polypropylene or PMMA spacers into the defect (Masquelet technique Stage 1; n = 11 rats per group) for the period established by the development phase. In each group, 6 of 11 rats were euthanized to compare the biological properties of polypropylene-induced membranes and PMMA-induced membranes using histological qualitative analysis, semiquantitative assessment of the bone morphogenic protein-2 content by immunostaining, and qualitative assessment of the mesenchymal stromal cell (MSC; CD31-, CD45-, CD90+, and CD73+ phenotypes) content by flow cytometry. Quantitative measurements from serum bone turnover markers were also performed. The five remaining rats of each group were used for Masquelet technique Stage 2, in which rat bone allografts were implanted in the induced membrane cavity after the polypropylene or PMMA spacers were removed. These rats recovered for 10 weeks before being euthanized for microCT quantitative measurements and bone histology qualitative assessment to evaluate and compare the extent of bone regeneration between groups. RESULTS Induced membrane analyses together with serum bone turnover measurements indicated that a 4-week interval time between stages was the most favorable. Removal of the induced membrane before grafting led to almost constant early implant failures with poor bone formation. Four-week-old rats with polypropylene-triggered induced membranes displayed similar histologic organization as rats with PMMA-driven induced membranes, without any difference in the cell density of the extracellular matrix (4933 ± 916 cells per mm2 for polypropylene versus 4923 ± 1284 cells per mm2 for PMMA; p = 0.98). Induced membrane-derived MSCs were found in both groups with no difference (4 of 5 with polypropylene versus 3 of 3 with PMMA; p > 0.99). Induced membrane bone morphogenic protein-2 immunolabeling and serum bone turnover marker levels were comparable between the polypropylene and PMMA groups. MicroCT analysis found that bone regeneration in the polypropylene group seemed comparable with that in the PMMA group (29 ± 26 mm3 for polypropylene versus 24 ± 18 mm3 for PMMA; p > 0.99). Finally, qualitative histological assessment revealed a satisfactory endochondral ossification maturation in both groups. CONCLUSION Using a critical-sized femoral defect model in rats, we demonstrated that polypropylene spacers could induce membrane encapsulation with histologic characteristics and bone regenerative capacities that seem like those of PMMA spacers. CLINICAL RELEVANCE In a same bone site, polymers with close physical properties seem to lead to similar foreign body reactions and induce encapsulating membranes with comparable bone healing properties. Polypropylene spacers made from disposable syringes could be a valuable alternative to PMMA. These results support the possibility of a cementless Masquelet technique in cases of PMMA shortage caused by a lack of resources.
Collapse
Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - James Charles Murison
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Arnaud de Rousiers
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Nicolas de l’Escalopier
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Didier Lutomski
- Tissue Engineering and Proteomics Team, Université Paris, Bobigny, France
| | | | - Marjorie Durand
- Military Biomedical Research Institute, Brétigny-sur-Orge, France
| |
Collapse
|
21
|
Yüceer-Çetiner E, Özkan N, Önger ME, Gülbahar MY, Keskin M. Is induced membrane technique effective in reconstruction of mandibular segmental bone defects? An experimental study. J Craniomaxillofac Surg 2021; 49:1130-1140. [PMID: 34561120 DOI: 10.1016/j.jcms.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/30/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022] Open
Abstract
This study aimed to compare the effectiveness of different graft materials using induced membrane technique for reconstruction of mandibular segmental bone defects. New Zealand rabbits were used as the experimental animal. As first-stage surgical procedure, segmental bone defects were created at the lower border of the mandibula in all groups. Polymethylmethacrylate (PMMA) cement was inserted into the defects. After 6 weeks, PMMA cement was removed in all groups. In the Control group, defect areas were left empty. Defects were filled with autogenous graft in the Autograft group, xenograft in the Xenograft group, and a mixture of autogenous graft and xenograft in the Autograft + Xenograft group. Histopathological, stereological, and immunohistochemical analyses were performed. A total of 40 New Zealand rabbits were used. Rabbits were randomly divided into four subgroups as Control, Autograft, Xenograft and Autograft + Xenograft groups (n = 10). When the groups were compared in terms of newly formed bone tissue volumes, significant difference was found between the Control group and Autograft group, Xenograft group and Autograft + Xenograft group (p < 0.001, p < 0.001, p = 0.003). The results of immunohistochemical examination were consistent with this finding. Stereological and immunohistochemical results can be used as a justification to adopt the induced membrane technique on an experimental basis in humans when it comes to the reconstruction of small segmental mandibular defects.
Collapse
Affiliation(s)
- Ezgi Yüceer-Çetiner
- Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Bahçeşehir University, Istanbul, Turkey.
| | - Nilüfer Özkan
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey
| | - Mehmet Emin Önger
- Department of Histology and Embryology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Mustafa Yavuz Gülbahar
- Department of Pathology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Metehan Keskin
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey
| |
Collapse
|
22
|
Contreras JJ, Díaz A, Beltrán M. Extensive humeral defect secondary to humeral shaft nonunion and chronic osteomyelitis treated with induced membrane technique augmented with fibula autograft: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:446-456. [PMID: 37588721 PMCID: PMC10426561 DOI: 10.1016/j.xrrt.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Julio J. Contreras
- Shoulder and Elbow Unit, Instituto Traumatológico, Santiago, Chile
- Department of Orthopedics and Trauma, Universidad de Chile, Santiago, Chile
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Alonso Díaz
- Shoulder and Elbow Unit, Instituto Traumatológico, Santiago, Chile
- Department of Orthopedics and Trauma, Universidad de Chile, Santiago, Chile
| | - Manuel Beltrán
- Shoulder and Elbow Unit, Instituto Traumatológico, Santiago, Chile
- Department of Orthopedics and Trauma, Universidad de Chile, Santiago, Chile
| |
Collapse
|
23
|
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.
Collapse
|
24
|
Alford AI, Nicolaou D, Hake M, McBride-Gagyi S. Masquelet's induced membrane technique: Review of current concepts and future directions. J Orthop Res 2021; 39:707-718. [PMID: 33382115 PMCID: PMC8005442 DOI: 10.1002/jor.24978] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/16/2020] [Accepted: 12/28/2020] [Indexed: 02/04/2023]
Abstract
Masquelet's induced membrane technique (MIMT) is a relatively new, two-stage surgical procedure to reconstruct segmental bone defects. First performed by Dr. Masquelet in the mid-1980s, MIMT has shown great promise to revolutionize critical-sized bone defect repair and has several advantages over its alternative, distraction osteogenesis (DO). Also, its success in extremely challenging cases (defects > 15 cm) suggests that its study could lead to discovery of novel biological mechanisms that might be at play during segmental defect healing and fracture non-union. MIMT's advantages over DO have led to a world-wide increase in MIMT procedures over the past decades. However, MIMT often needs to be repeated and so the average initial success rate in adults lags significantly behind that of DO (86% vs 95%, respectively). The autologous foreign-body membrane created during the first stage by the immune system's response to a polymethyl methacrylate bone cement spacer is critical to supporting the morselized bone graft implanted in the second stage. However, the biological and/or physical mechanisms by which the membrane supports graft to bone union are unclear. This lack of knowledge makes refining MIMT and improving the success rates through technique improvements and patient selection a significant challenge and hinders wider adoption. In this review, current knowledge from basic, translational, and clinical studies is summarized. The dynamics of both stages under normal conditions as well as with drug or material perturbations is discussed along with perspectives on high-priority future research directions.
Collapse
Affiliation(s)
- Andrea I. Alford
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO
| | - Mark Hake
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | | |
Collapse
|
25
|
Mathieu L, Durand M, Collombet JM, de Rousiers A, de l'Escalopier N, Masquelet AC. Induced membrane technique: a critical literature analysis and proposal for a failure classification scheme. Eur J Trauma Emerg Surg 2020; 47:1373-1380. [PMID: 33226484 DOI: 10.1007/s00068-020-01540-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/31/2020] [Indexed: 02/08/2023]
Abstract
The reconstruction of long-bone segmental defects remains challenging, with the three common methods of treatment being bone transport, vascularized bone transfer, and the induced membrane technique (IMT). Because of its simplicity, replicability, and reliability, usage of IMT has spread all over the world in the last decade, with more than 300 papers published in the PubMed literature database on this subject so far. Most of the clinical studies have reported high rates of bone union, yet some also include more controversial results with frequent complications and revision surgeries. At the same time, various experimental research efforts have been designed to understand and improve the biological properties of the induced membrane. This literature review aims to provide an overview of IMT clinical results in terms of bone union and complications and to compare them with those of other reconstructive procedures. In light of our findings, we then propose an original classification scheme of IMT failures distinguishing between preventable and nonpreventable failures.
Collapse
Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Marjorie Durand
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Jean-Marc Collombet
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Arnaud de Rousiers
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Nicolas de l'Escalopier
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Alain-Charles Masquelet
- Department of Orthopedic, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| |
Collapse
|
26
|
Xie J, Liu D, Wang H, Long H, Zhu Y, Hu Y, Zeng M. Effects of topical mechanical stability on the formation of Masquelet membrane in a rabbit radial defect model. Sci Rep 2020; 10:18939. [PMID: 33144701 PMCID: PMC7609590 DOI: 10.1038/s41598-020-76112-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/23/2020] [Indexed: 12/24/2022] Open
Abstract
The exact mechanism of Masquelet technique is unknown. This study intends to explore the effects of topical mechanical stability on the formation of Masquelet membrane. Segmental radius shaft defect was created in all rabbits, which were filled with polymethylmethacrylate (PMMA) in Non-fixation group, and with PMMA fixed with plates in Fixation group, and subjected to no disposal in control group. The topical stability of PMMA and plates were monitored via X-ray and mechanical test. And the membranes were excised for further Histological, IHC and Western-Blotting analysis 4 and 6 weeks post-operatively. X-ray revealed no sign of plates loosening, or shift of PMMA. Mechanical tests revealed superior topical stability by plates. Pathological examinations suggested that vascularized and osteogenic membranes were formed around PMMA. IHC and Western-Blotting analysis revealed that both Fixation and Non-fixation group exerted significant effects on the expression of Ki67, COL I, and CD31 positive cells, as well as the protein expression of osteogenic (RUNX2, ALP) and angiogenic (VEGFA, TGF-β1) factors. And compared with membrane in Non-fixation group, Fixing PMMA spacer with plates caused a significant increase in osteogenic and angiogenic expression. This study indicates that rigid fixation provided by plate in Masquelet technique positively alters the quality of membrane formed surrounding PMMA, in terms of significantly osteogenic and angiogenic potential.
Collapse
Affiliation(s)
- Jie Xie
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Donghao Liu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Haoyi Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Haitao Long
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yong Zhu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yihe Hu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Min Zeng
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China.
| |
Collapse
|
27
|
Gohel N, Senos R, Goldstein SA, Hankenson KD, Hake ME, Alford AI. Evaluation of global gene expression in regenerate tissues during Masquelet treatment. J Orthop Res 2020; 38:2120-2130. [PMID: 32233004 PMCID: PMC7494657 DOI: 10.1002/jor.24676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/19/2020] [Accepted: 03/25/2020] [Indexed: 02/04/2023]
Abstract
The Masquelet induced-membrane (IM) technique is indicated for large segmental bone defects. Attributes of the IM and local milieu that contribute to graft-to-bone union are unknown. Using a rat model, we compared global gene expression profiles in critically sized femoral osteotomies managed using a cement spacer as per Masquelet to those left empty. At the end of the experiment, IM and bone adjacent to the spacer were collected from the Masquelet side. Nonunion tissue in the defect and bone next to the empty defect were collected from the contralateral side. Tissues were subjected to RNA isolation, sequencing, and differential expression analysis. Cell type enrichment analysis suggested the IM and the bone next to the polymethylmethacrylate (PMMA) spacer were comparatively enriched for osteoblastic genes. The nonunion environment was comparatively enriched for innate and adaptive immune cell markers, but only macrophages were evident in the Masquelet context. iPathwayGuide was utilized to identify cell signaling pathways and protein interaction networks enriched in the Masquelet environment. For IM vs nonunion false-discovery rate correction of P values rendered overall pathway differences nonsignificant, and so only protein interaction networks are presented. For the bone comparison, substantial enrichment of pathways and networks known to contribute to osteogenic mechanisms was revealed. Our results suggest that the PMMA spacer affects the cut bone ends that are in contact with it and at the same time induces the foreign body reaction and formation of the IM. B cells in the empty defect suggest a chronic inflammatory response to a large segmental osteotomy.
Collapse
Affiliation(s)
- Nishant Gohel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rafael Senos
- Department of Morphology, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Steven A. Goldstein
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kurt D. Hankenson
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark E. Hake
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Address correspondence to Mark E. Hake: Department of Orthopaedic Surgery, University of Michigan School of Medicine, 1500 E Medical Center Drive, 2912 Taubman Center SPC 5328; Ann Arbor, MI 48109; fax: +1-734-647-3277; telephone: +734-936-9839;
| | - Andrea I. Alford
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Address correspondence to Andrea I. Alford: Department of Orthopaedic Surgery, University of Michigan School of Medicine, A. Alfred Taubman Biomedical Sciences Research Building, Room 2009, Ann Arbor, MI, 48109; fax: +1-734 -647-0003; telephone: +1-734-615-6104;
| |
Collapse
|
28
|
Masquelet AC. The induced membrane technique. Orthop Traumatol Surg Res 2020; 106:785-787. [PMID: 32782174 DOI: 10.1016/j.otsr.2020.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/30/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Alain C Masquelet
- Service de chirurgie orthopédique, hôpital Saint-Antoine, Sorbonne university, 184, rue du Faubourg St-Antoine, 75571 Paris, France.
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Gindraux F, Loisel F, Bourgeois M, Oudina K, Melin M, de Billy B, Sergent P, Leclerc G, Petite H, Auber F, Obert L, Pluvy I. Induced membrane maintains its osteogenic properties even when the second stage of Masquelet's technique is performed later. Eur J Trauma Emerg Surg 2019; 46:301-312. [PMID: 31321472 DOI: 10.1007/s00068-019-01184-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE Previous clinical studies have shown the effectiveness of bone repair using two-stage surgery called the induced membrane (IM) technique. The optimal wait before the second surgery is said to be 1 month. We have been successfully performing the IM technique while waiting an average of 6 months to carry out the second stage. We hypothesised that the IM maintains its beneficial capabilities, even at a later second stage, and that there is no relation between the speed of bone union and the wait between the first and second stage. We sought to explore the biological properties of 'older' IMs sampled to substantiate our clinical observations. METHODS Thirty-four patients with a critical size defect were treated with the IM technique. In seven of these patients, pieces of the IM were collected 4.2-14.7 months after the first surgery. IM-derived cell phenotype and osteogenic potential were investigated using in vitro studies (n = 4) while IM nature and function were investigated by histology and immunohistochemistry (n = 3). RESULTS The median wait before the second surgery was 5.8 months [range 1.2-14.7] and bone healing occurred at 7.6 months [range 2.5-49.9] for 26 patients. IMs aged 4.2-14.7 months contained mesenchymal stromal cells with in vitro osteogenic potential and corresponded to a multipotent tissue with osteogenic and chondrogenic capabilities contributing to osteogenesis over time. CONCLUSION This preliminary study suggests the IM retains its powerful osteogenic properties over time and that waiting longer between the two surgeries does not delay bone union.
Collapse
Affiliation(s)
- Florelle Gindraux
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France. .,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.
| | - François Loisel
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France.,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
| | - Michael Bourgeois
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France
| | - Karim Oudina
- Laboratory of Bioengineering and Biomechanics for Bone Articulation (B2OA-UMR CNRS 7052), University Paris Diderot, Paris, France
| | | | - Benoit de Billy
- Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.,Paediatric Surgery Department, University Hospital of Besancon, Besancon, France
| | - Pauline Sergent
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France
| | - Gregoire Leclerc
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France
| | - Hervé Petite
- Laboratory of Bioengineering and Biomechanics for Bone Articulation (B2OA-UMR CNRS 7052), University Paris Diderot, Paris, France
| | - Frederic Auber
- Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.,Paediatric Surgery Department, University Hospital of Besancon, Besancon, France
| | - Laurent Obert
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France.,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
| | - Isabelle Pluvy
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France.,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
| |
Collapse
|