Reconstruction of an extensive soft tissue and bone defect of the first metatarsal with the use of Masquelet technique: a case report

Gunshot Injury With Bone Defect of the First Metatarsal Bone A Presentation of 2 Cases Treated With an Iliac Crest Structural Graft, Internal Fixation, and Bone Morphogenic Protein 2

Gunshot injuries to the foot with segmental bone defects can be challenging to treat. When the vascularity is intact and the soft tissues allows, the goal should be to reconstruct the bony defect. We present 2 cases of a gunshot injury to the foot with a defect of the first metatarsal bone. Both cases were treated, with favorable outcome, with a structural iliac crest graft, internal fixation, and bone morphogenic protein 2.Level of Evidence: V, cases series, technical.

A Two-Stage Diabetic Foot Salvage Using Synthetic Bone Void Filler and Lesser Toe Fillet Flap: A Case Report

CASE

A 54-year-old type 2 diabetic man with a diabetic forefoot ulcer and osteomyelitis successfully underwent a staged reconstruction to salvage his foot. An antibiotic-carrying bone void filler was used to decrease the infection burden after initial debridement. The fifth toe fillet flap was performed to cover the large soft-tissue defect. The patient returned to baseline ambulation at the 1-year follow-up with a well-incorporated flap.

CONCLUSION

This case highlights the utility of combining an antibiotic-carrying bone void filler and a toe fillet flap in a two-stage approach to salvage complex diabetic foot ulcers.

Expression of VEGF in Peripheral Serum Is a Possible Prognostic Factor in Bone-Regeneration via Masquelet-Technique-A Pilot Study

Two-step Masquelet-technique established a new procedure in the treatment of osseous defects, addressing prerequisites postulated by the “diamond concept”. Increase in blood perfusion and growth factors are enhanced by the “Masquelet-membrane”. To describe this, we measured serum levels of Vascular Endothelial Growth Factor (VEGF) of patients with atrophic non-unions of long bones undergoing Masquelet-technique. From over 500 non-union patients undergoing Masquelet-technique with prospective follow-up we randomly selected 30 patients. 23 were included, 7 lost to follow-up or excluded because of incomplete data. Serum was drawn at specified intervals before and after surgery. Patients were followed for at least 6 months after step 2. Classification into both groups was performed according to radiological results and clinical outcome 6 months after step 2. Concentration of VEGF in patients’ serum was performed via ELISA. 14 achieved osseous consolidation (responder group), 9 cases did not (non-responder). Responders showed a significant increase of serum-VEGF in the first and second week when compared to the preoperative values of step 1. Non-responders showed a significant increase of VEGF in the second week after Steps 1 and 2. Comparison of groups showed significantly higher increase of serum-VEGF week2 after step 1 and preoperative to step 2 for responders. Results show one possibility of illustrating therapeutic progress by monitoring growth factors and possibly allowing prognostic conclusions thereof. This might lead to a more targeted treatment protocol.

Induced Membrane Technique (Masquelet) for Bone Defects in the Distal Tibia, Foot, and Ankle: Systematic Review, Case Presentations, Tips, and Techniques

Bone defects to the distal tibia, foot, and ankle can be challenging to reconstruct. The induced membrane (Masquelet) technique has become an established method of repair for challenging areas of bone loss. It has been applied in acute open fractures, chronic nonunion, osteomyelitis, and gout erosion. This article presents a systematic review of distal tibia, foot, and ankle results using the Masquelet procedure, which should be considered in cases of challenging critical bone loss. Further work is needed to present large studies of the procedure on foot and ankle patients to consolidate current knowledge.

Induced Membrane Bone Grafting Technique for Treatment of Large Postinfectious Acetabular Bone Defects

Management of large acetabular bone defects is challenging. The Masquelet technique has successfully reconstructed segmental defects in long bones arising from trauma, tumors, or infection but not been described for large acetabular defects. We present 3 cases of large acetabular bone defects arising from chronic prosthetic joint infection, treated via a novel induced membrane bone grafting technique, drawn from the Masquelet technique. All cases showed satisfactory clinical and radiological outcomes at midterm follow-up. This technique holds promise and can be an alternative means when treating large acetabular bone defects.

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

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

Successful fifth metatarsal bulk autograft reconstruction of thermal necrosis post intramedullary fixation

Reamed intramedullary (IM) screw fixation for proximal fifth metatarsal fractures is technically challenging with potentially devastating complications if basic principles are not followed. A case of an iatrogenic fourth-degree burn after elective reamed IM screw fixation of a proximal fifth metatarsal fracture in a high-level athlete is reported. The case was complicated by postoperative osteomyelitis with third-degree soft-tissue defect. This was successfully treated with staged autologous bone graft reconstruction, tendon reconstruction, and local bi-pedicle flap coverage. The patient returned to competitive-level sports, avoiding the need for fifth ray amputation. Critical points of the IM screw technique and definitive reconstruction are discussed. Bulk autograft reconstruction is a safe and effective alternative to ray amputation in segmental defects of the fifth metatarsal.Level of evidence V.

Anatomic three-dimensional model-assisted surgical planning for treatment of pediatric hip dislocation due to osteomyelitis

Management of pediatric septic coxarthritis and osteomyelitis of the femur is challenging, and the sequelae of multiplanar hip joint deformity with instability are difficult to reconstruct. The inadequacy of a suitable device for fixing small bones during pediatric osteotomy is a hindrance to the correction of subluxated hip joints and deformed femurs in children. Two-dimensional axial images and three-dimensional (3D) virtual models representing the patient’s individual anatomy are usually reserved for more complex cases of limb deformity. 3D printing technology can be used for preoperative planning of complex pediatric orthopedic surgery. However, there is a paucity of literature reports regarding the application of 3D-printed bone models for pediatric post-osteomyelitis deformity. We herein present a case of a 4-year-old boy who underwent treatment for post-osteomyelitis deformity. We performed corrective surgery with Pemberton osteotomy of the right hip, multilevel varus derotation osteotomy of the right femur, and immobilization with a hip spica cast. A 3D-printed bone model of this patient was used to simulate the surgery, determine the proper osteotomy sites, and choose the appropriate implant for the osteotomized bone. A satisfactory clinical outcome was achieved.

Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis

OBJECTIVE

This study was to compare the effectiveness of Masquelet technique versus Ilizarov bone transport in the treatment of lower extremity bone defects following posttraumatic osteomyelitis.

PATIENTS AND METHODS

We retrospectively reviewed 39 patients who had been treated at our department for lower extremity bone defects following posttraumatic osteomyelitis. They were 30 males and 9 females with a mean age of 39.18 (range, 12-63 years). The infected bone defects involved 26 tibias and 13 femurs. The mean length of the bone defects after radical debridement was 6.76cm (range, 2.7-15.7cm). Masquelet technique (MT, group A) was used in 20 patients and Ilizarov bone transport (IBT, group B) in 19 ones. The measurements were bone outcomes (union, deformity, infection and leg-length discrepancy) and functional outcomes (significant limping, joint contracture, soft tissue dystrophy, pain and inactivity).

RESULTS

The mean follow-up after removal of the apparatus was 25.26 months (range, 14-51 months). The mean finite fixator time was 10.15 months (range, 8-14 months) in group A versus 17.21 months (range, 11-24 months) in group B. The bone outcomes were similar between groups A and B [excellent (5 vs. 7), good (10 vs.9), fair (4 vs. 2) and poor (1 vs. 1)]; group A showed better functional outcomes than group B [excellent (8 vs. 3), good (9 vs. 6), fair (3 vs. 8) and poor (0 vs. 2)].

CONCLUSIONS

In the treatment of segmental lower extremity bone defects following posttraumatic osteomyelitis, both IBT and MT can lead to satisfactory bone results while MT had better functional results, especially in femoral cases. IBT should be preferred in cases of limb deformity and MT may be a better choice in cases of periarticular bone defects.

Surgical Management of Complex Lower-Extremity Trauma With a Long Hindfoot Fusion Nail: A Case Report

High-energy injuries can result in complete or partial loss of the talus. Ipsilateral fractures to the lower limb increase the complexity of surgical management, and treatment is guided by previous case reports of similar injuries. A case of complex lower-extremity trauma with extruded and missing talar body and ipsilateral type IIIB open tibia fracture is presented. Surgical limb reconstruction and salvage was performed successfully with a single orthopaedic implant in a manner not described previously in the literature. The purpose of this case report is to present the novel use of a single orthopaedic implant for treatment of a complex, open traumatic injury. Previous case reports in the literature have described the management of complete or partial talar loss. We describe the novel use of a long hindfoot fusion nail and staged bone grafting to achieve tibiocalcaneal arthrodesis for the treatment of complex lower-extremity trauma.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case study.

Biomaterial-Stabilized Soft Tissue Healing for Healing of Critical-Sized Bone Defects: the Masquelet Technique

Critical-sized bone defects present a significant burden to the medical community due to their challenging treatment. However, a successful limb-salvaging technique, the Masquelet Technique (MT), has significantly improved the prognosis of many segmental bone defects in helping to restore form and function. Although the Masquelet Technique has proven to be clinically effective, the physiology of the healing it induces is not well understood. Multiple modifiable factors have been implicated by various surgical and research teams, but no single factor has been proven to be critical to the success of the Masquelet Technique. In this review the most recent clinical and experimental evidence that supports and helps to decipher the traditional Masquelet, as well as the modifiable factors and their effect on the success of the technique are discussed. In addition, future developments for the integration of the traditional Masquelet Technique with the use of alternative biomaterials to increase the effectiveness and expand the clinical applicability of the Masquelet Technique are reviewed.

Possibility of one-stage surgery to reconstruct bone defects using the modified Masquelet technique with degradable calcium sulfate as a cement spacer: A case report and hypothesis

In addition to autologous bone graft, vascularized fibular autograft and Ilizarov bone transfer, the Masquelet technique is another effective method to reconstruct bone defects. This technique was initially proposed in 1986 and consists of two stages. At the first stage, radical debridement is required and subsequently, a polymethylmethacrylate (PMMA) cement spacer is implanted at the site of the bone defects. At the second stage, when the PMMA-induced membrane is formed 6-8 weeks later, the cement spacer is carefully removed in order to not disturb the induced membrane and the bone graft is performed to fill the bone defects. Although this technique has resulted in satisfactory outcomes in the reconstruction of bone defects, the PMMA spacer used to induce membrane is not degradable and requires surgical removal. In recent years, calcium sulfate has been used as a localized antibiotic delivery vehicle and bone substitute due to its superiorities over PMMA, particularly its completely degradable nature. The present study identified that calcium sulfate can also induce the formation of a membrane. In addition, we hypothesized that the degradability of calcium sulfate may allow one-stage reconstruction of bone defects. The current study presents a clinical case report and review of the literature.

Reconstruction of septic diaphyseal bone defects with the induced membrane technique

Septic segmental bone voids of the diaphysis are difficult to manage. The induced membrane technique by Masquelet has been successfully used to reconstruct segmental defects more than 20 cm. Our article describes a series of 13 cases with extensive posttraumatic bone loss of the metatarsal, tibial, femoral and radial bones after septic injuries followed by multiple surgical interventions. Antibiotic-impregnated polymethyl methacrylate (PMMA) cement spacers were implanted after successful eradication of bacterial infections of soft tissue and bones. After a mean of 9.8 weeks, body-induced membranes were established and the cements spacers removed. To fill up the bone void, cancellous bone autografts were implanted into the membranes. The follow-up examination after 24 months revealed bony union in all cases and favorable functional results. The induced membrane technique has shown to be effective in treating bone defects of upper and lower extremity bone defects.