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Fischer C, Schipper S, Langwald S, Klauke F, Kobbe P, Mendel T, Hückstädt M. [Modified Masquelet technique : Technique of the induced membrane in the course of time]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:729-737. [PMID: 39110137 PMCID: PMC11420378 DOI: 10.1007/s00113-024-01474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 09/26/2024]
Abstract
The reconstruction of long bone defects as a result of primary traumatic, secondary infection or tumor-related loss of substance continues to represent a surgical challenge. Callus distraction via segment transport, vascularized bone transfer and the induced membrane technique (IMT) are established methods of reconstruction. In recent decades IMT has experienced increasing popularity due to its practicability, reproducibility and reliability. At the same time, the original technique has undergone numerous modifications. The results are correspondingly heterogeneous. This overview is intended to explain the basic principles of IMT and to provide an overview of the various modifications and their complications.
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Affiliation(s)
- C Fischer
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland.
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland.
| | - S Schipper
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - S Langwald
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
| | - F Klauke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - P Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - T Mendel
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - M Hückstädt
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
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Husebye EE, Andreassen GS, Stødle AH. 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. Foot Ankle Spec 2024:19386400241278026. [PMID: 39292490 DOI: 10.1177/19386400241278026] [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: 09/19/2024]
Abstract
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.
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Shen J, Wei Z, Wu H, Wang X, Wang S, Wang G, Luo F, Xie Z. The induced membrane technique for the management of infected segmental bone defects. Bone Joint J 2024; 106-B:613-622. [PMID: 38821512 DOI: 10.1302/0301-620x.106b6.bjj-2023-1443.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Aims The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction.
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Affiliation(s)
- Jie Shen
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
- Trauma Medical Centre, Department of Orthopaedic Surgery, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Wei
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hongri Wu
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
- Department of Orthopaedics, Navy 905 Hospital, Navy Medical University, Shanghai, China
| | - Xiaohua Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shulin Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Guanglin Wang
- Trauma Medical Centre, Department of Orthopaedic Surgery, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Luo
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhao Xie
- Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
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Wakefield SM, Papakostidis C, Giannoudis VP, Mandía-Martínez A, Giannoudis PV. Distraction osteogenesis versus induced membrane technique for infected tibial non-unions with segmental bone loss: a systematic review of the literature and meta-analysis of available studies. Eur J Trauma Emerg Surg 2024; 50:705-721. [PMID: 37921889 PMCID: PMC11249469 DOI: 10.1007/s00068-023-02375-w] [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: 05/02/2023] [Accepted: 09/29/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Infected tibial non-unions with associated bone loss can be challenging to manage. At present, the two main methods utilized in the management of these fractures include the Ilizarov technique of Distraction Osteogenesis (DO) using external fixator devices, or alternatively, the Induced Membrane Technique (IMT), devised by Masquelet. As there is a paucity of data directly comparing the outcomes of these techniques, there is no universal agreement on which strategy a surgeon should choose to use. AIMS This systematic review and meta-analysis aimed to summarize the outcomes of both DO and IMT, in terms of primary outcomes (bone union and infection elimination), and secondary outcomes (complication rates and functional outcomes). METHODS A PRISMA strategy was used. Medline, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar library databases were interrogated using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated using OCEBM and GRADE systems. RESULTS Thirty-two studies with 1136 subjects met the inclusion criteria. With respect to the primary outcomes of interest, union was observed in 94.6% (DO method) and 88.0% (IMT method); this difference, however, was not significant between the two techniques (p = 0.45). In addition, infection elimination rates were also higher in the Ilizarov DO group when compared to Masquelet (Mq) IMT (93.0% vs 80.4% respectively). Again, no significant difference was observed (p = 0.06). For all secondary outcomes assessed (unplanned re-operations, re-fracture rates amputation rate), no statistically significant differences were documented between the treatment options. CONCLUSION This study demonstrated that there is no clinical difference in outcomes for patients treated with Ilizarov DO versus Mq IMT techniques. The evidence base at present is relatively sparse and, therefore, we would recommend for further Level I studies to be conducted, to make more meaningful conclusions.
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Affiliation(s)
- Sophia M Wakefield
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Costas Papakostidis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Vasileios P Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Alfonso Mandía-Martínez
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics Surgery, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK.
- NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK.
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He J, Xia X, Zuo B, Tang J, Wang P. A review of 10 patients treated with the masquelet technique and microsurgical technique combined for Gustilo type III open tibial fractures. BMC Musculoskelet Disord 2024; 25:362. [PMID: 38714945 PMCID: PMC11075234 DOI: 10.1186/s12891-024-07478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Open tibial fractures often include severe bone loss and soft tissue defects and requires complex reconstructive operations. However, the optimal treatment is unclear. METHODS This retrospective study enrolled patients with Gustilo type III open tibial fractures from January 2018 to January 2021 to assess the clinical utility of Masquelet technique together with microsurgical technique as a combined strategy for the treatment of open tibial fractures. The demographics and clinical outcomes including bone union time, infection, nonunion and other complications were recorded for analysis. The bone recovery quality was evaluated by the AOFAS Ankle-Hindfoot Scale score and the Paley criteria. RESULTS We enrolled 10 patients, the mean age of the patients and length of bone defects were 31.7 years (range, 23-45 years) and 7.5 cm (range, 4.5-10 cm) respectively. Bone union was achieved for all patients, with an average healing time of 12.2 months (range, 11-16 months). Seven patients exhibited a bone healing time of less than 12 months, whereas 3 patients exhibited a bone healing time exceeding 12 months. No significant correlation was found between the length of bone loss and healing time. In addition, no deep infection or nonunion was observed, although 2 patients experienced wound fat liquefaction with exudates and 1 patient presented with a bloated skin flap. The average AOFAS Ankle-Hindfoot Scale score was 80.5 (range, 74-85), and all patients were evaluated as good or exellent based on the Paley criteria. CONCLUSIONS Our study indicated that the use of the Masquelet technique and the microsurgical technique as a combined strategy is safe and effective for the treatment of Gustilo type III open tibial fractures.
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Affiliation(s)
- Jingxuan He
- Department of Orthopedics, General Hospital of the Yangtze River Shipping, Wuhan city, Hubei province, 430010, China
| | - Xiaofeng Xia
- Department of Orthopedics, General Hospital of the Yangtze River Shipping, Wuhan city, Hubei province, 430010, China
| | - Bing Zuo
- Department of Orthopedics, General Hospital of the Yangtze River Shipping, Wuhan city, Hubei province, 430010, China
| | - Jiaguo Tang
- Department of Orthopedics, General Hospital of the Yangtze River Shipping, Wuhan city, Hubei province, 430010, China
| | - Peng Wang
- Department of Orthopedics, General Hospital of the Yangtze River Shipping, Wuhan city, Hubei province, 430010, China.
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Dulic O, Abazovic D, Gavrilovic G, Rasovic P, Janjic N, Obradovic M, Ninkovic S, Tosic M, Lalic I, Baljak B, Milinkov M, Maric D. A case series utilizing bone marrow aspirate concentrate, cancellous bone autograft, platelet-rich plasma and autologous fibrin for the treatment of femur nonunions. Regen Med 2024; 19:225-237. [PMID: 39118529 PMCID: PMC11321269 DOI: 10.1080/17460751.2024.2352250] [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: 12/11/2023] [Accepted: 04/29/2024] [Indexed: 08/10/2024] Open
Abstract
Aim: To assess the efficacy of a bioregenerative scaffold derived from bone marrow aspirate, cancellous bone autograft, platelet-rich plasma and autologous fibrin in treating supracondylar femur nonunions. Methods & materials: Three patients with nonunions following multiple surgical failures underwent bone stabilization and the application of a novel bioregenerative scaffold. x-rays and subjective scales were collected before surgery and at 6, 12 and 24 months post-surgery. Results: All nonunions exhibited healing with sufficient callus formation, as confirmed radiologically. After 6 months, all patients resumed full weight-bearing walking without pain. Statistical analysis showed improvements in all scales compared with pre-surgical values. Conclusion: This method presents itself as an option for treating supracondylar femur nonunions following multiple surgical failures.
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Affiliation(s)
- Oliver Dulic
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
- Atlas Hospital, Belgrade, Serbia
- University Business Academy, Novi Sad, Serbia. Faculty of Farmacy, Novi Sad
| | | | | | - Predrag Rasovic
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
| | - Natasa Janjic
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
| | - Mirko Obradovic
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
| | - Srdjan Ninkovic
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
| | - Milan Tosic
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
| | - Ivica Lalic
- University Business Academy, Novi Sad, Serbia. Faculty of Farmacy, Novi Sad
| | - Branko Baljak
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
| | - Milan Milinkov
- Medical Faculty, University of Novi Sad,Serbia. University Clinical Center of Vojvodina
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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.
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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.
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Garabano G, Amadei Enghelmayer RE, Perez Alamino L, Viollaz GM, Pesciallo CA. The polymicrobial infection affects the infection recurrence rate (not failure) in treating femoral and tibial bone defects with the Masquelet technique-a comparative retrospective analysis of 54 patients with mono- and polymicrobial infections. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:789-797. [PMID: 37702802 DOI: 10.1007/s00590-023-03689-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/13/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION This study evaluated whether polymicrobial infection affects reoperation rates due to infection recurrence and treatment failure with the Masquelet technique in infected posttraumatic segmental bone defects of the femur and tibia. METHODS We retrospectively analyzed patients treated between 2012 and 2021 in two trauma referral centers. We evaluated demographic data, injury, treatment, infection recurrence, failures, and bone healing rates according to whether the infection was mono- or polymicrobial. After uni-bivariate analysis between patients with polymicrobial and monomicrobial infection, we identified the variables associated with infection recurrence and failure through multivariate analysis. RESULTS We analyzed 54 patients, 30 (55.55%) with tibial and 24 (44.44%) femoral segmental bone defects, with a mean follow-up of 41.7 ± 15.0 months. Forty-four (81.48%) presented monomicrobial, and 10 (18.51%) polymicrobial infections. Comparatively, the need for soft tissue reconstruction and the infection recurrence rate was significantly higher in patients with polymicrobial infections. There was no significant difference in the failure rate (20 vs. 6.81% p = 0.23). Multivariable logistic regression analysis identified the polymicrobial infection as the only independent variable associated with infection recurrence (Odds Ratio = 11.07; p = 0.0017). CONCLUSION Our analysis suggests that polymicrobial infection is associated with a higher risk of infection recurrence in treating the femur and tibia segmental bone defects with the Masquelet technique. This information can help surgeons to inform patients about this and give them a realistic expectation of the outcome and the possibility of reoperation.
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Affiliation(s)
- Germán Garabano
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina.
- Scientific Advisory Committee, British Hospital of Buenos Aires, Buenos Aires, Argentina.
| | - Rafael E Amadei Enghelmayer
- Orthopaedic and Trauma Surgery Department, Hospital Alta Complejidad Cuenca Alta, RP6 Km 92.5 PC 1814, Cañuelas, Buenos Aires, Argentina
| | - Leonel Perez Alamino
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Gonzalo M Viollaz
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
- Orthopaedic and Trauma Surgery Department, Hospital Alta Complejidad Cuenca Alta, RP6 Km 92.5 PC 1814, Cañuelas, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
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Wang H, Zhang Z, Wang W, Sun X. Scooping Technique to Acquire Cancellous Bone for Grafting in the Masquelet Procedure: A Retrospective Study. Indian J Orthop 2023; 57:1267-1275. [PMID: 37525726 PMCID: PMC10386989 DOI: 10.1007/s43465-023-00909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/08/2023] [Indexed: 08/02/2023]
Abstract
Background The Masquelet procedure is effective in overcoming large bone defects; however, the limited number of cancellous bone and donor site complications remains a challenge. We developed a scooping technique to harvest sufficient cancellous bone from iliac crests for grafting during the Masquelet procedure. We hypothesized that this method would be efficient and safe. Methods This retrospective study included 13 patients who underwent the Masquelet procedure with cancellous bone grafting using the scooping technique. The following parameters were observed: (1) duration and total volume of cancellous bone extraction; (2) amount of bleeding and drainage fluid, and Visual Analog Scale (VAS) score of pain at the donor site during different periods; and (3) complications and bone regeneration at the ilium at the final follow-up. Results The median follow-up duration was 17 months. There were 3 unilateral and 10 bilateral extraction sites. The mean total amount extracted, extraction duration, bleeding, and drainage were 39 mL, 23 min, 49 mL, and 44 mL, respectively. Only three patients felt pain (VAS score: 1 point) at the final follow-up. Postoperatively, one case each of hematoma and lateral femoral cutaneous nerve injury supervened, and no infections or other complications occurred. The last computed tomography examination showed varying degrees of bone regeneration in the ilium. Conclusion The scooping technique for the iliac crest produced a substantial amount of autogenous cancellous bone using a small incision. It retained the appearance and morphology of the ilium with few complications. We believe it is a successful and safe option for treating bone defects.
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Affiliation(s)
- Hui Wang
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
- Fuzong Clinical Medical College of Fujian Medical University, 88 Jiaotong Road, Taijiang District, Fuzhou, 350025 Fujian China
| | - Zhihong Zhang
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
| | - Wanming Wang
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
| | - Xiaotang Sun
- Department of Orthopedics Surgery, The 900th Hospital of Joint Logistics Support Force, PLA 156 West Second Ring North Road, Gulou District, Fuzhou, 350025 Fujian China
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Ahmed H, Shakshak M, Trompeter A. A review of the Masquelet technique in the treatment of lower limb critical-size bone defects. Ann R Coll Surg Engl 2023. [PMID: 37367227 DOI: 10.1308/rcsann.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
The need for bone tissue to heal effectively is paramount given its role in the mechanical support of tissues. Bone has a very good natural healing potential in comparison with most other tissue types, largely regenerating to its pre-injury state in the vast majority of cases. Certain factors such as high energy trauma, tumour resection, revision surgery, developmental deformities and infection can lead to the formation of bone defects, where the intrinsic healing potential of bone is diminished owing to bone loss. Various approaches to resolving bone defects exist in current practice, each with their respective benefits and drawbacks. These include bone grafting, free tissue transfer, Ilizarov bone transport and the Masquelet induced membrane technique. This review focuses on evaluating the Masquelet technique, discussing its method and underlying mechanisms, the effectiveness of certain modifications, and its potential future directions.
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Affiliation(s)
- H Ahmed
- St George's, University of London, UK
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Papakostidis C, Giannoudis PV. Reconstruction of infected long bone defects: Issues and Challenges. Injury 2023; 54:807-810. [PMID: 36828614 DOI: 10.1016/j.injury.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- Costas Papakostidis
- Consultant Orthopaedic and Trauma Surgeon, Assistant Director of the Orthopaedic Department, Limassol General Hospital, Limassol, Cyprus.
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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Garabano G, Pesciallo CA. Definitive fixation in the first stage of the induced membrane technique for septic segmental bone defects. Why not? J Clin Orthop Trauma 2023; 37:102089. [PMID: 36632342 PMCID: PMC9826849 DOI: 10.1016/j.jcot.2022.102089] [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: 07/11/2022] [Revised: 12/02/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Background Infected segmental bone defects (I-SBD) are challenging and complex to manage. This study aimed to show the outcomes achieved in I-SBD of the femur and tibia, treated with the induced membrane technique performing a definitive bone stabilization in the first stage. Methods We retrospectively reviewed 30 patients with infected non-articular segmental bone defects of the femur (n = 11) and tibia (n = 19), operated consecutively between January 2015 and May 2021. The need for fixation exchange, bone defect length, allo/autograft ratio used, bone healing, reoperation (discriminating between mechanical and infection-related causes), and failure rates (graft resorption or nonunion) were recorded. Results Fixation in the first stage was performed with 28 (93.33%) intramedullary nails, ten coated with antibiotic cement, and 2 (6.67%) locked plates. None were removed during the second stage of the technique. The mean length of the bone defects was 5cm (range 3.5-12). The most commonly used allo-/autograft ratio was 50-50. The bone healing rate was 93.33% (n = 28), with a median follow-up of 7 months (range 3-12). The reoperation rate due to mechanical instability was 3.33% (n = 1) and for recurrence of infection was 10.0% (n = 3). The overall failure rate was 6.67% (n = 2). The median follow-up was 42 months (range 12-85). Conclusion Masquelet technique appears feasible and effective in treating infected segmental bone defects of the femur and tibia. Definitive fixation at the first stage showed a success rate of 93.33%, with a re-operation rate of 10.0% related to infection.
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Affiliation(s)
- Germán Garabano
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Buenos Aires, Argentina
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Functional outcomes and health-related quality of life after reconstruction of segmental bone loss in femur and tibia using the induced membrane technique. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04714-9. [PMID: 36460763 PMCID: PMC10374690 DOI: 10.1007/s00402-022-04714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION The induced membrane technique (IMT), frequently called Masquelet technique, is an operative, two-staged technique for treatment of segmental bone loss. Previous studies mainly focused on radiological outcome parameters and complication rates, while functional outcomes and health-related quality of life after the IMT were sparsely reported. MATERIALS AND METHODS Retrospective study containing of a chart review as well as a clinical and radiological follow-up examination of all patients treated with the IMT at a single institution. The clinical outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the Short-Form-36 (SF-36) and the visual analog scale (VAS) for pain. The radiographic evaluation contained of standard anteroposterior and lateral, as well as hip-knee-ankle (HKA) radiographs. RESULTS Seventeen patients were included in the study. All had suffered high-energy trauma and sustained additional injuries. Ten bone defects were localized in the femur and seven in the tibia. Ten patients underwent additional operative procedures after IMT stage 2, among them three patients who contracted a postoperative deep infection. The median LEFS was 59 (15-80), and the SF-36 physical component summary (PCS) and mental component summary (MCS) were 41.3 (24.0-56.1) and 56.3 (13.5-66.2), respectively. The median length of the bone defect was 9 (3-15) cm. In 11 patients, union was obtained directly after IMT stage 2. Bone resorption was observed in two patients. At follow-up, 16 of the 17 bone defects had healed. The median follow-up was 59 months (13-177). CONCLUSION Our results show a high occurrence of complications after IMT stage 2 in segmental bone defects of femur and tibia requiring additional operative procedures. However, fair functional outcomes as well as a good union rate were observed at follow-up.
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Lu Y, Lai C, Lai P, Yu Y. Induced Membrane Technique for the Management of Segmental Femoral Defects: A Systematic Review and Meta-Analysis of Individual Participant Data. Orthop Surg 2022; 15:28-37. [PMID: 36444955 PMCID: PMC9837298 DOI: 10.1111/os.13604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 12/02/2022] Open
Abstract
Several modifications of the induced membrane technique (IMT) have been reported, but there is no consensus regarding their results and prognosis. Moreover, most studies have focused on tibial defects; no meta-analysis of the treatment of femoral defects using the IMT has been reported. This systematic review and meta-analysis aimed to identify the potential risk factors of post-procedural complications following the treatment of segmental femoral defects using the IMT. A comprehensive search was performed on the Cochrane Library, EBSCO, EMBASE, Ovid, PubMed, Scopus, and Web of Science databases, using the keywords "femur," "Masquelet technique," and "induced membrane technique." Original articles composed in English, having accessible individual patient data, and reporting more than two cases of bony defect or nonunion of femur or more than five cases of any body part were included. Post-procedural bone graft infections, final union status, and union time after second-stage operation were analyzed. Fourteen reports, including 90 patients, were used in this study. External fixation in second-stage surgery had an odds ratio of 9.267 for post-procedural bone graft infection (p = 0.047). The odds ratio of post-procedural bone graft infection and age >65 years for final non-union status was 51.05 (p = 0.003) and 9.18 (p = 0.042). Shorter union time was related to impregnated antibiotics in the spacer (p = 0.005), transplanting all-autologous grafts (p = 0.042), and the application of intramedullary nails as the second-stage fixation method (p = 0.050). The IMT appears to be reasonable and reproducible for femoral segmental bone defects. Several preoperative and surgical factors may affect post-procedural complications and union time.
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Affiliation(s)
- Yi Lu
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
| | - Chih‐Yang Lai
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
| | - Po‐Ju Lai
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
| | - Yi‐Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
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Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique. Eur J Trauma Emerg Surg 2022; 49:951-964. [PMID: 36443494 PMCID: PMC10175460 DOI: 10.1007/s00068-022-02162-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022]
Abstract
Abstract
Purpose
The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis–Ilizarov method (ILF), or with Masquelet technique (MIF).
Methods
Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF).
Results
The average defect length was 5.6 cm (2.6–9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459–£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9.
Conclusions
The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.
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Masquelet technique in military practice: specificities and future directions for combat-related bone defect reconstruction. Mil Med Res 2022; 9:48. [PMID: 36050805 PMCID: PMC9438145 DOI: 10.1186/s40779-022-00411-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022] Open
Abstract
Because of its simplicity, reliability, and replicability, the Masquelet induced membrane technique (IMT) has become one of the preferred methods for critical bone defect reconstruction in extremities. Although it is now used worldwide, few studies have been published about IMT in military practice. Bone reconstruction is particularly challenging in this context of care due to extensive soft-tissue injury, early wound infection, and even delayed management in austere conditions. Based on our clinical expertise, recent research, and a literature analysis, this narrative review provides an overview of the IMT application to combat-related bone defects. It presents technical specificities and future developments aiming to optimize IMT outcomes, including for the management of massive multi-tissue defects or bone reconstruction performed in the field with limited resources.
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Effect of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) with Hydroxyapatite Carrier in Induced Membrane Technique: A Retrospective Propensity Score-Matched Study. J Orthop Trauma 2022; 36:301-308. [PMID: 34732658 DOI: 10.1097/bot.0000000000002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) with hydroxyapatite (HA) carrier augmentation in managing critical-sized bone defect (CSBD) with induced membrane technique (IMT). DESIGN Retrospective comparative study. SETTING Academic level I trauma center. PATIENTS/PARTICIPANTS The study included 14 patients who underwent rhBMP-2 with HA carrier (rhBMP-2/HA) augmentation in IMT for managing CSBD (BMP group). Moreover, 14 patients who underwent IMT without rhBMP-2 augmentation were matched by propensity score analysis (non-BMP group). INTERVENTION IMT with or without rhBMP-2/HA augmentation. MAIN OUTCOME MEASUREMENT Changes in quality and quantity measurements of grafted bone to regenerated bone using serial computed tomography. RESULTS In the BMP and non-BMP groups, the changes in densities from grafted bone to regenerated bone were +379.63 Hounsfield unit and +248.55 Hounsfield unit (P = 0.034), changes in dense bone percentage were +37.52% and +23.31% (P = 0.027), corticalization rates under the plate were 79.70% and 39.30% (P = 0.007), changes in volume were -20.77% and -23.35% (P = 0.812), union rates were 85.71% and 78.57% (P = 0.622), numbers of patients requiring additional procedures were 4 and 3 (P = 0.663), and time to union were 316.3 and 585.45 days (P = 0.040), respectively. CONCLUSIONS RhBMP-2/HA augmentation increases the density of regenerated bone, enhances corticalization under the plate, and shortens the time to union while managing CSBD with IMT. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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18
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Induced membrane technique for acute bone loss and nonunion management of the tibia. OTA Int 2022; 5:e170. [PMID: 35949266 PMCID: PMC9359030 DOI: 10.1097/oi9.0000000000000170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022]
Abstract
Objectives: To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects. Design: Retrospective study of prospectively collected data (Level IV). Setting: Level I trauma center in the UK. Patients/Participants: Consecutive patients with tibial nonunions and open fractures associated with bone loss. Intervention: Two-stage Masquelet Procedure for the tibia. Main Outcome Measurements: Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union. Results: There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4–8 cm) and an 88.2% union rate at a mean of 8 months (range 5–18 months). Mean range of motion was 95 degrees of knee flexion (range 80°–130°). All patients but 2 returned to their previous occupation. Conclusions: The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications.
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Borzunov DY, Kolchin SN, Mokhovikov DS, Malkova TA. Ilizarov bone transport combined with the Masquelet technique for bone defects of various etiologies (preliminary results). World J Orthop 2022; 13:278-288. [PMID: 35317249 PMCID: PMC8935333 DOI: 10.5312/wjo.v13.i3.278] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/11/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Ilizarov bone transport (IBT) and the Masquelet induced membrane technique (IMT) have specific merits and shortcomings, but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies, including congenital deficiencies. Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments.
AIM To combine IBT and IMT for the management of severe tibial defects and pseudarthrosis, and present preliminary results of this technological solution.
METHODS Seven adults with post-traumatic tibial defects (subgroup A) and nine children (subgroup B) with congenital pseudarthrosis of the tibia (CPT) were treated with the combination of IMT and IBT after the failure of previous treatments. The mean number of previous surgeries was 2.0 ± 0.2 in subgroup A and 3.3 ± 0.7 in subgroup B. Step 1 included Ilizarov frame placement and spacer introduction into the defect to generate the induced membrane which remained in the interfragmental gap after spacer removal. Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane, its compression and docking for consolidation without grafting. The outcomes were retrospectively studied after a mean follow-up of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B.
RESULTS The “true defect” after resection was 13.3 ± 1.7% in subgroup A and 31.0 ± 3.0% in subgroup B relative to the contralateral limb. Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, respectively. Total duration of external fixation was 397 ± 9.2 and 270.1 ± 16.3 d, including spacer retention time of 42.4 ± 4.5 and 55.8 ± 6.6 d, in subgroups A and B, respectively. Bone infection was not observed. Postoperative complications were several cases of pin-tract infection and regenerate deformity in both subgroups. Ischemic regeneration was observed in two cases of subgroup B. Complications were corrected during the course of treatment. Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B. One non-united CPT case was further treated with the Ilizarov compression method only and achieved union. After a follow-up period of two to three years, refractures occurred in four cases of united CPT.
CONCLUSION The combination of IMT and IBT provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention. Refractures may occur in severe CPT.
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Affiliation(s)
- Dmitry Y Borzunov
- Department of Taumatology and Orthopedics, Ural State Medical University, Ekaterinburg 620109, Russia
| | - Sergey N Kolchin
- Orthopaedic Department 4, Ilizarov National Medical Research Center for Traumatology and Orthopaedics, Kurgan 640014, Russia
| | - Denis S Mokhovikov
- Orthopaedic Department 4, Ilizarov National Medical Research Center for Traumatology and Orthopaedics, Kurgan 640014, Russia
| | - Tatiana A Malkova
- Department of Medical Information and Analysis, Ilizarov National Medical Research Center for Traumatology and Orthopaedics, Kurgan 640014, Russia
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20
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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.
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21
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Chloros GD, Howard A, Kanakaris NK, Giannoudis PV. Case report: Restoration of an open 12 cm femoral defect treated with the Masquelet technique in a 20-year-old polytrauma. Trauma Case Rep 2021; 36:100563. [PMID: 34901374 PMCID: PMC8639465 DOI: 10.1016/j.tcr.2021.100563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Infected post-traumatic femoral defects are challenging to treat, and limited options exist. The case of a 20-year-old polytrauma male who sustained a segmental femur fracture involving the femoral neck, distal femur and an intermediate diaphyseal bone defect of 12 cm is presented. The patient declined a long-term frame in his femur. The 2-stage Masquelet procedure resulted in successful outcome with limb preservation. Femoral bone defects are challenging to treat. Patients do not tolerate bone transport well in this area. Successful management of a 12cm femoral bone defect is reported in a 20-year old patient using the Masquelet technique.
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Affiliation(s)
- George D Chloros
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Anthony Howard
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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22
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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: 7] [Impact Index Per Article: 2.3] [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.
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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
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Dalisson B, Charbonnier B, Aoude A, Gilardino M, Harvey E, Makhoul N, Barralet J. Skeletal regeneration for segmental bone loss: Vascularised grafts, analogues and surrogates. Acta Biomater 2021; 136:37-55. [PMID: 34626818 DOI: 10.1016/j.actbio.2021.09.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
Massive segmental bone defects (SBD) are mostly treated by removing the fibula and transplanting it complete with blood supply. While revolutionary 50 years ago, this remains the standard treatment. This review considers different strategies to repair SBD and emerging potential replacements for this highly invasive procedure. Prior to the technical breakthrough of microsurgery, researchers in the 1960s and 1970s had begun to make considerable progress in developing non autologous routes to repairing SBD. While the breaktthrough of vascularised bone transplantation solved the immediate problem of a lack of reliable repair strategies, much of their prior work is still relevant today. We challenge the assumption that mimicry is necessary or likely to be successful and instead point to the utility of quite crude (from a materials technology perspective), approaches. Together there are quite compelling indications that the body can regenerate entire bone segments with few or no exogenous factors. This is important, as there is a limit to how expensive a bone repair can be and still be widely available to all patients since cost restraints within healthcare systems are not likely to diminish in the near future. STATEMENT OF SIGNIFICANCE: This review is significant because it is a multidisciplinary view of several surgeons and scientists as to what is driving improvement in segmental bone defect repair, why many approaches to date have not succeeded and why some quite basic approaches can be as effective as they are. While there are many reviews of the literature of grafting and bone repair the relative lack of substantial improvement and slow rate of progress in clinical translation is often overlooked and we seek to challenge the reader to consider the issue more broadly.
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Strain R, Vun JSH, Harwood PJ. Simultaneous induced membrane technique to reconstruct an obliterated floating knee. Trauma Case Rep 2021; 36:100546. [PMID: 34712768 PMCID: PMC8531655 DOI: 10.1016/j.tcr.2021.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 10/13/2021] [Indexed: 12/01/2022] Open
Abstract
The induced membrane technique, first described by Masquelet, is a powerful surgical approach that can be used to address segmental bone loss of various aetiologies. Despite ongoing debate regarding optimal delivery, the indications and limits of its application have been tested in increasingly complex situations, highlighting its considerable potential. We present a case of a devastating open lower limb injury with simultaneous femoral and ipsilateral tibial bone loss including articular injury on both sides of the joint. The Masquelet technique was used to successfully address both segments of bone loss within the same limb.
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Affiliation(s)
- Ritchie Strain
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK
| | - James S H Vun
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Paul J Harwood
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK
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25
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Chen ZY, Gao S, Zhang YW, Zhou RB, Zhou F. Antibacterial biomaterials in bone tissue engineering. J Mater Chem B 2021; 9:2594-2612. [PMID: 33666632 DOI: 10.1039/d0tb02983a] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bone infection is a devastating disease characterized by recurrence, drug-resistance, and high morbidity, that has prompted clinicians and scientists to develop novel approaches to combat it. Currently, although numerous biomaterials that possess excellent biocompatibility, biodegradability, porosity, and mechanical strength have been developed, their lack of effective antibacterial ability substantially limits bone-defect treatment efficacy. There is, accordingly, a pressing need to design antibacterial biomaterials for effective bone-infection prevention and treatment. This review focuses on antibacterial biomaterials and strategies; it presents recently reported biomaterials, including antibacterial implants, antibacterial scaffolds, antibacterial hydrogels, and antibacterial bone cement types, and aims to provide an overview of these antibacterial materials for application in biomedicine. The antibacterial mechanisms of these materials are discussed as well.
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Affiliation(s)
- Zheng-Yang Chen
- Orthopedic Department, Peking University Third Hospital, Beijing 100191, China.
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26
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Andrzejowski P, Masquelet A, Giannoudis PV. Induced Membrane Technique (Masquelet) for Bone Defects in the Distal Tibia, Foot, and Ankle: Systematic Review, Case Presentations, Tips, and Techniques. Foot Ankle Clin 2020; 25:537-586. [PMID: 33543716 DOI: 10.1016/j.fcl.2020.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Paul Andrzejowski
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds LS1 3EX, UK
| | - Alain Masquelet
- Department of Orthopaedic Surgery, Avicenne Hospital AP-HP, 123, route de Stalingrad, Bobiny 93009, France
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds LS1 3EX, UK.
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27
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Mathieu L, Durand M, Collombet JM, de Rousiers A, de l'Escalopier N, Masquelet AC. Induced membrane technique: a critical literature analysis and proposal for a failure classification scheme. Eur J Trauma Emerg Surg 2020; 47:1373-1380. [PMID: 33226484 DOI: 10.1007/s00068-020-01540-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/31/2020] [Indexed: 02/08/2023]
Abstract
The reconstruction of long-bone segmental defects remains challenging, with the three common methods of treatment being bone transport, vascularized bone transfer, and the induced membrane technique (IMT). Because of its simplicity, replicability, and reliability, usage of IMT has spread all over the world in the last decade, with more than 300 papers published in the PubMed literature database on this subject so far. Most of the clinical studies have reported high rates of bone union, yet some also include more controversial results with frequent complications and revision surgeries. At the same time, various experimental research efforts have been designed to understand and improve the biological properties of the induced membrane. This literature review aims to provide an overview of IMT clinical results in terms of bone union and complications and to compare them with those of other reconstructive procedures. In light of our findings, we then propose an original classification scheme of IMT failures distinguishing between preventable and nonpreventable failures.
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Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Marjorie Durand
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Jean-Marc Collombet
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Arnaud de Rousiers
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Nicolas de l'Escalopier
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Alain-Charles Masquelet
- Department of Orthopedic, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
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28
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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.
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29
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Choufani C, Demoures T, de l'Escalopier N, Chapon MP, Barbier O, Mathieu L. Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad. Eur J Trauma Emerg Surg 2020; 48:593-599. [PMID: 32857239 DOI: 10.1007/s00068-020-01471-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/21/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad. METHODS A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application. RESULTS Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage. CONCLUSIONS This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.
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Affiliation(s)
- Camille Choufani
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France.
| | - Thomas Demoures
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France
| | - Nicolas de l'Escalopier
- Clinic of Orthopedics, Traumatology and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France
| | - Marie-Pauline Chapon
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France
| | - Olivier Barbier
- Clinic of Orthopedics and Traumatology, Begin Military Hospital, 69 Avenue de Paris, 94160, Saint-Mandé, France
- French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75005, Paris, France
| | - Laurent Mathieu
- Clinic of Orthopedics, Traumatology and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France
- French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75005, Paris, France
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30
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Repeated Induced-Membrane Technique Failure without Infection: A Series of Three Consecutive Procedures Performed for a Single Femur Defect. Case Rep Orthop 2020; 2020:8892226. [PMID: 32832179 PMCID: PMC7429766 DOI: 10.1155/2020/8892226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/27/2020] [Accepted: 07/27/2020] [Indexed: 02/08/2023] Open
Abstract
A 40-year-old male was treated using the induced-membrane technique (IMT) for a noninfected, 9 cm long femoral bone defect complicating a lengthening procedure. The interesting case feature lies in the three consecutive IMT procedures that were necessary to achieve complete bone repair in this unusual clinical situation. The first procedure failed because of the lack of graft revascularization likely related to an induced-membrane (IM) alteration demonstrated by histological observations. The second IMT procedure led to partial graft integration interrupted by the elongation nail breakage. At last, the third procedure fully succeeded after nail exchange and iterative iliac bone grafting. Complete bone union was achieved with a poor functional recovery one year after the last procedure and four years following the first cement spacer implantation. By means of clinical and histological observations, we demonstrated that the first and the second IMT failures had two distinct origins, namely, biological and mechanical causes, respectively. Although simple, a successful IMT procedure is not so easy to complete.
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Mathieu L, Tossou-Odjo L, de l'Escalopier N, Demoures T, Baus A, Brachet M, Masquelet AC. Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects. INTERNATIONAL ORTHOPAEDICS 2020; 44:1647-1653. [PMID: 32696330 DOI: 10.1007/s00264-020-04735-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/14/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT). METHODS A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2. RESULTS Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence. CONCLUSIONS Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.
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Affiliation(s)
- Laurent Mathieu
- Clinic of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,Department of surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Léon Tossou-Odjo
- Clinic of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Nicolas de l'Escalopier
- Clinic of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Thomas Demoures
- Clinic of Orthopedics and Traumatology, Bégin Military Hospital, 69 avenue de Paris, 94160, Saint-Mandé, France
| | - Arnaud Baus
- Clinic of Esthetic and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Michel Brachet
- Clinic of Esthetic and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Alain Charles Masquelet
- Clinic of Orthopedics, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
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