Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The Free Tissue Transfer-Masquelet-Reamer-Irrigator-Aspirator Bone Graft Orthoplastic Approach for Lower Extremity Reconstruction

SUMMARY

The management of critical-sized bone and soft-tissue defects of the lower extremity poses unique challenge to reconstructive surgeons. The aim of this article is to present the authors' current orthoplastic approach for the management of extended (more than 6 cm) osteocutaneous defects of the lower extremity, based on a sequential combination of two stages: free flap for soft-tissue coverage and the Masquelet technique (first step) followed by reamer-irrigator-aspirator cancellous bone graft and definitive osteosynthesis (second step). This study was a single-center observational retrospective review of prospectively collected data. Adult patients (>18 years of age) with segmental bone loss of the lower extremity caused by acute trauma (Gustilo type IIIB fracture) or nonunion (septic/aseptic) who were treated with the free flap for soft-tissue coverage-Masquelet technique-reamer-irrigator-aspirator approach between January of 2017 and December of 2020 were included. Time of consolidation and early and late complications were recorded. A total of 11 patients (nine male patients and two female patients) with a mean age of 45.8 years were identified. The average bone gap length (standard deviation) was 87.3 (24.9) mm. An anterolateral thigh flap was harvested in all cases. The average duration of the first stage (i.e., time from antibiotic cement spacer placement and free flap to time of bone grafting) was 50.4 days (range, 40 to 62 days). Bone consolidation was achieved in all cases after an average period (standard deviation) of 20.4 (3.3) weeks, with acceptable functional outcomes. The free flap for soft-tissue coverage-Masquelet technique-reamer-irrigator-aspirator approach could be considered a viable option in patients with segmental critical-sized bone defects associated with a large soft-tissue deficit of the lower extremity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Induced Membrane Technique for the Treatment of Infected Forearm Nonunion: A Retrospective Study

PURPOSE

Infected forearm nonunion remains a challenge for the hand surgeon. Autologous bone grafting within an induced membrane following implantation of a cement spacer, also known as the Masquelet technique, is a procedure used for addressing segmental bone defects. This report summarized our experience using this technique to treat the infected forearm nonunion.

METHODS

We retrospectively reviewed a series of 32 patients treated for infected forearm nonunion by the 2-stage Masquelet technique between 2009 and 2018. There was an infected nonunion of the ulna in 28 patients and an infected nonunion of the radius in 4 patients. All patients had undergone an average of 2.7 procedures before presenting at our institution. Treatment involved a staged procedure in which an antibiotic-impregnated cement spacer was implanted into the bone defect following debridement without internal fixation. It was left in place for 4-6 weeks, during which time a membrane formed around the cement spacer. In the second stage, the induced membrane was incised, and the cement spacer was removed. The defect was then filled with cancellous autograft with the addition of internal fixation. Postoperative radiographs were taken for the evaluation of bone healing. The functional results of the affected forearm were evaluated for motion loss of elbow or wrist and rotation loss of forearm.

RESULTS

All nonunions healed without recurrent infection or loosening of internal fixation at the time of final follow-up. All the patients showed substantial functional improvement, with excellent results in 14 patients, satisfactory results in 13, and unsatisfactory results in 5.

CONCLUSIONS

The induced membrane technique is an effective solution for infected forearm nonunion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Safety and efficacy of a novel retrograde route for femoral bone graft harvesting by Reamer-Irrigator-Aspirator: a pilot study on 24 patients

Background

The Reamer–Irrigator–Aspirator system was initially developed to reduce fat embolism and thermic necrosis during reamed intramedullary nail fixation of femoral shaft fractures. Currently, this system is used in extended applications including accessing large volume of autologous bone graft, as alternative for iliac crest harvesting. Antegrade femoral bone graft harvesting using the Reamer-Irrigator-Aspirator system is considered the standard technique. The aim of our study is to evaluate the efficacy (bone graft volume) and the complications (blood loss, postoperative pain, and incidence of iatrogenic fractures) of the Reamer–Irrigator–Aspirator system through the retrograde femoral route in a series of patients with post-traumatic bone defects or nonunions.

Methods

A non-controlled single center retrospective observational cohort study was conducted in a level1 trauma center to evaluate all patients who were treated using the RIA system. Between November 2015 and May 2019, 24 patients (8 women and 16 men; mean age: 41 years [range 27–55 years]) with bone defects or nonunions underwent bone graft harvesting using the Reamer–Irrigator–Aspirator system through retrograde femoral route. Postoperative pain, complications, and bone graft volume were analyzed. Inclusion criteria was patients older than 18 years with a diagnosis of post-traumatic bone defect or associated tibial or femoral nonunion, with minimum 6-months follow, treated using the RIA. We hypothesized that the retrograde route of the RIA system is a safe and efficacious method for bone harvesting.

Results

The average volume of collected graft was 45 cc (range 30–60 cc). In 83% of the cases, bone grafting was sufficient, while in 17% it was necessary to add iliac crest bone graft to completely fill the bone defect. A mean drop in postoperative hemoglobin of 4.1 g / dL (range 0.5–6.0 g / dL) was evidenced. In 4 cases (33%), a unit of packed red blood cells was required. Regarding postoperative pain, visual analogue scale after 3 months postoperatively was 1.6 in average. After 6 months, the value has decreased to 0.4. There were no perioperative or postoperative complications at 6-month follow-up.

Conclusion

In this limited case series, large volumes of bone graft were harvested using the retrograde route of the RIA system and there were no intra-/ postoperative complications observed at 6-month follow-up. Therefore this novel technique appears safe and efficacious.

However, it’s important to highlight that future prospective controlled studies are necessary to validate the insights from this pilot study.

The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review

Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.

Outcomes and complications of the reamer irrigator aspirator versus traditional iliac crest bone graft harvesting: a systematic review and meta-analysis

BACKGROUND

The reamer irrigator aspirator (RIA) is a relatively recent device that is placed in the medullary canal of long bones to harvest a large volume of bone marrow, which is collected in a filtered canister. This study compares outcomes and complications of the RIA versus a traditional iliac crest bone graft (ICBG) for the treatment of bone defects.

METHODS

This meta-analysis was conducted according to the PRISMA guidelines. The Embase, Google Scholar, PubMed, and Scopus databases were accessed in June 2021. All clinical trials comparing the RIA and ICBG with a minimum of 6 months follow-up were included.

RESULTS

Data from 4819 patients were collected. The RIA group demonstrated lower site pain (P < 0.0001), fewer infections (P = 0.001), and a lower rate of adverse events (P < 0.0001). The ICBG group demonstrated a greater rate of bone union (P < 0.0001). There was no difference between groups in VAS (P = 0.09) and mean time to union (P = 0.06).

CONCLUSION

The current evidence supports the use of the RIA, given its low morbidity and short learning curve.

Effects of Combination of BMP7, PFG, and Autograft on Healing of the Experimental Critical Radial Bone Defect by Induced Membrane (Masquelet) Technique in Rabbit

Background

Healing of large segmental bone defects can be challenging for orthopedic surgeons. This research was conducted to provide further insight into the effects of BMP7 in combination with autograft and platelet fibrin glue (PFG) on bone regeneration by Masquelet technique (MT).

Methods

Twenty five domestic male rabbits, more than 6 months old, weighing 2.00±0.25 kg were randomly divided into five equal groups as follows: MT-blank cavity (without any biological or synthetic materials) (1), blank cavity (2), MT-autograft (3), MT-autograft-BMP7 (4), and MT-BMP7-PFG (5). A 20 mm segmental defect was made in radial bone in both forelimbs. The Masquelet technique was done in all groups except group 2. The study was evaluated by radiology, biomechanics, histopathology and scanning electron microscopy.

Results

The results showed that Masquelet technique enhanced the healing process, as, the structural and functional criteria of the injured bone showed significantly improved bone healing (P<0.05). Treatment by PFG-BMP7, Autograft-BMP7, and autograft demonstrated beneficial effects on bone healing. However, Autograft-BMP7 was more effective than autograft in healing of the radial defect in rabbits.

Conclusion

Our findings introduce the osteogenic materials in combination with Masquelet technique as an alternative for reconstruction of the big diaphyseal defects in the long bones in animal models. Our findings may be useful for clinical application in future.

Aeromonas hydrophilia-infected nonunion of a closed tibial fracture in a healthy adolescent: A case report

Aeromonas hydrophilia can cause soft tissue infection in both immunocompromised and healthy persons. A healthy 15-year-old adolescent fell into a ditch after a scooter accident and sustained a right distal tibial shaft closed fracture, a right femoral shaft closed fracture, and a dirty laceration over the medial aspect of the distal thigh above the right knee. After empiric antibiotics and radical debridement of the contaminated wound, a femoral interlocking nail and tibial external fixator were applied. However, acute osteomyelitis later presented in his femur and tibia, and Aeromonas hydrophilia grew in cultures from the knee wound and the fracture sites. During the follow-up, his tibia became an infected nonunion, and was successfully treated with the induced membrane technique. In an otherwise healthy patient with a closed fracture, Aeromonas hydrophilia can cause acute osteomyelitis and necrotizing fasciitis by spreading from a nearby contaminated wound. Exposure to water is a risk factor for Aeromonas hydrophilia infection.

Autologous Bone Grafting in Trauma and Orthopaedic Surgery: An Evidence-Based Narrative Review

Autologous bone grafting is common in trauma and orthopaedic surgery. Both the Reamer Irrigator Aspirator (RIA) and Iliac Crest Bone Graft (ICBG) aim to obtain autologous bone graft. Although the process of harvesting a bone graft is considered simple, complications may occur. This study examined morbidity and pain at the donor site, blood loss, and iatrogenic fractures, comparing RIA and ICBG. The source of the autologous bone graft, the alternative graft sites, and the storage modalities of the harvested bone marrow were also evaluated. In May 2021, PubMed, Embase, Scopus, and Google Scholar were accessed, with no time constraints. RIA may produce greater blood loss, but with less morbidity and complications, making it a potential alternative source of bone grafting.

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

OBJECTIVES

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

DESIGN

Retrospective study.

SETTING

Level one trauma center.

PATIENTS/PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

3D geometry of femoral reaming for bone graft harvesting

The reamer-irrigator-aspirator (RIA) technique allows to collect large bone graft amounts without the drawbacks of iliac crest harvesting. Nevertheless, clinical cases with occurrence of femur fractures have been reported. Therefore, this study aimed to systematically investigate the three-dimensional geometry of the reamed bone as a function of the reaming diameter and its influence on the associated potential fracture pattern. Forty-five intact fresh-frozen human cadaveric femora underwent computed tomography (CT). They were randomized to three groups (n = 15) for reaming at a diameter of either 1.5 mm (Group 1), 2.5 mm (Group 2) or 4.0 mm (Group 3) larger than their isthmus using RIA. Reaming was followed by a second CT scan, biomechanical testing until failure and a third CT scan. All CT scans of each femur were aligned via rigid registration, and fracture lines were visualized. Subsequently, a decrease in wall thickness, cross-sectional area, and harvested bone volume have been evaluated. The total volume of the bone graft was significantly higher for Group 3 (7.8 ± 2.9 ml) compared to Group 1 (2.9 ± 1.1 ml) and Group 2 (3.0 ± 1.1 ml). The maximal relative decrease of the wall thickness was located medially (72.7%) in the third (61.4%), fourth (18.2%) and second (9.1%) eighth for all groups. As the diameter of the reaming increased, an overlap of the fracture line with the maximal relative decrease in wall thickness and a maximal average relative decrease of the cross-sectional area became more frequent. This suggests that a reaming-associated fracture is most likely to occur in this region.

Autologous bone graft: Is it still the gold standard?

Bone grafting has over 100 years of successful clinical use. Despite the successes of autograft bone transplantation, complications of bone grafting are significant, mostly at the donor site. This article reviews the biology of fracture healing, the properties of bone grafts, and reviews the specific advantages and problems associated with autograft bone. Recent techniques such as the Reamer Irrigator Aspirator are described, which has dramatically reduced complications of bone autograft harvesting.

Masquelet’s induced membrane technique for the reconstruction of post-traumatic, open-grade distal femur fracture with bone defect

Introduction:

Reconstruction of complex, open-grade distal femur fracture with bone defect presents an orthopaedic surgeon with a distinctive challenge as they are often associated with contaminated, compromised soft tissue and poor host condition. Conventional techniques like vascularized fibula transfer, autologous bone grafting or distraction osteogenesis focus mainly over bone union without taking infection control into consideration. The aim of this study is to evaluate the outcome of induced membrane technique in the reconstruction of open distal femur fracture with bone defect.

Methods:

10 such patients were retrospectively evaluated. Union was considered when a minimum of two cortices were seen on a radiograph. Knee Society Score was used to evaluate the functional outcome.

Results:

The average length of the defect was 5.7cm (3–10 cm) with mean interval period between the two stages being 42.7 days (34–51 days). Internal fixation was carried out in all cases. In 7 patients we used a mixture of cancellous autograft and cancellous allograft mixed in a ratio of 3:1. In the remaining 3 patients we used only cancellous autograft. Radiological union was achieved in all patients with mean union time of 8.5 months (7–11 months). Mean knee score was 79 (69–86) and mean function score was 71.5 (60–80).

Conclusion:

The induced membrane technique is an economical, technically less demanding technique for reconstruction of distal femur fracture with bone defects. The results are reproducible with a high success rate and without the need of any special instrumentation. It bestows infection control and prevents graft resorption. Long reconstructive period and donor site morbidity are matters of concern.

Influence of the Reamer-Irrigator-Aspirator diameter on femoral bone strength and amount of harvested bone graft - a biomechanical cadaveric study

BACKGROUND

Treatment of large bone defects is still related to unsolved problems in orthopaedic trauma surgery. Minimally invasive intramedullary reaming with the use of the Reamer-Irrigator-Aspirator (RIA) device allows autograft harvesting of large bone graft amounts from the medullary canal of the femur. The aim of this study was to investigate the influence of RIA diameter on femoral bone strength and amount of harvested bone graft in a human cadaveric model.

METHODS

Forty-five pairs human cadaveric femora were randomized to 3 paired groups with 15 pairs each. One femur of each pair was reamed with RIA at a diameter of either 1.5 mm (group 1), 2.5 mm (group 2) or 4.0 mm (group 3) larger than its isthmus, whereas its contralateral femur was left intact without reaming. The amount of harvested bone graft was determined for each specimen and all femora were destructively tested in internal rotation under 750 N axial compression to calculate their torsional stiffness and torque at failure.

RESULTS

Significant reduction in torsional stiffness was detected after reaming in group 3 (p = 0.03) in contrast to groups 1 and 2 where no such significant reduction was observed (p ≥ 0.34). Torque at failure was significantly reduced after reaming in all 3 groups (p ≤ 0.04). Collected bone graft amount in group 3 was significantly bigger compared to groups 1 and 2 (p ≤ 0.04).

CONCLUSIONS

Reaming with RIA diameter of 4.0 mm larger than the isthmus of the femur seems to influence considerably its torsional stiffness, however, it allows harvesting of a significantly bigger bone graft amount.

Bone-Graft Resorption Reduced by the Induced Membrane Technique and Factors Affecting Volumetric Changes: An Analysis of 120 Serial Computed Tomographic Scans in 40 Patients

BACKGROUND

Little is known about the volumetric changes of grafted bone over time when using the induced membrane technique. This study investigates the volumetric changes of bone graft using serial computed tomographic (CT) scans following the induced membrane technique.

METHODS

Patients with critical-sized bone defects had serial CT scans after undergoing bone-grafting using the induced membrane technique. CT scans to evaluate the volume of bone graft were obtained immediately postoperatively and at 6 and 12 months. The change in the volume of bone graft was determined at 6 and 12 months postoperatively. Patient demographic characteristics, the location and composition of the bone graft, and the type of fixation construct were analyzed.

RESULTS

Forty patients met inclusion criteria. There were 27 tibiae and 13 femora with a mean size defect of 8.6 cm (range, 2.5 to 20.6 cm). Of these patients, 21 received autograft with cancellous bone graft and 19 received mixed autogenous bone with demineralized bone matrix (DBM) at a mean time of 17 weeks after the membrane formation. For the first 6 months, there was an overall osseous resorption of -9.9%. The overall graft volume from 6 to 12 months demonstrated an increase of osseous volume by +1.6%. For the entire 12-month period, there was a mean graft volume resorption of -8.3%. A correlation was found between the early volumetric changes of grafted bone and the percentage of DBM in the graft mixture. A correlation was also found between the late volumetric changes and the location of defect or the type of fixation.

CONCLUSIONS

At 1 year after use of the induced membrane technique for the treatment of a critical-sized bone defect, resorption of the grafted bone averaged -8.3%. The volumetric changes were influenced by the property of the grafted bone, the fixation construct, and the location of the defect.

LEVEL OF EVIDENCE

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

Interposition Arthroplasty of the Elbow After Proximal Ulna Reconstruction With the Masquelet Technique: A Case Report

INTRODUCTION

Periarticular bone loss in the upper extremity poses challenges for a functional reconstruction.

CASE

A 32-year-old man sustained an open elbow fracture-dislocation from a high-velocity gunshot resulting in significant bone and soft-tissue loss about the proximal ulna. He underwent bony reconstruction with the Masquelet technique and delayed interposition arthroplasty in an attempt to preserve function.

CONCLUSIONS

The Masquelet technique, coupled with interposition arthroplasty, may be used to address significant articular bony defects about the proximal ulna, allowing patients to maintain function and limit pain.

Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System

BACKGROUND

Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account.

MATERIALS AND METHODS

We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls.

CONCLUSION

The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes.

HOW TO CITE THIS ARTICLE

Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020;15(2):106-116.

Managing bone loss in open fractures

Segmental bone loss continues to pose substantial clinical and technical challenges to orthopaedic surgeons. While several surgical options exist for the treatment of these complex patients, there is not a clear consensus or specific guidelines on the optimal management of these injuries as a whole. Many factors must be taken into consideration when planning surgery for these individuals. In order for these techniques to yield optimal results, each injury must be approached in a step-wise and multidisciplinary fashion to ensure that care is taken in bone and wound bed preparation, that soft tissues are healthy and free of contaminants, and that the patient's medical condition has been optimized. Through this article, we will answer relevant questions and discuss common obstacles and challenges encountered with these complex injuries. We will also review the many treatment options available or in development to address this problem.

The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence

BACKGROUND

The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures.

METHODS

A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide".

RESULTS

The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old.

CONCLUSIONS

General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.

Similarities and Differences of Induced Membrane Technique Versus Wrap Bone Graft Technique

BACKGROUND

There are no reports on the similarities and differences between induced membrane (IM) technique and wrap bone graft(WBG) technique.

OBJECTIVE

The aims of this study are to investigate the effects of IM technique and WBR technique in repairing segmental bone defects, and to analyze the similarities and differences between them.

MATERIALS AND METHODS

66 patients of tibial segmental bone defects treated by IM technique and WBG technique were retrospectively analyzed. Aged 13-69 years old with an average of 35.3 years old. IM technique was divided into early IM group (bone grafting at 6-8 weeks of bone cement filling) and late IM group (bone grafting after 8 weeks of bone cement filling). WBG was divided into titanium mesh group and line suturing cortical bone blocks group. There were 11 cases, 25 cases, 10 cases and 20 cases in the early IM group, late IM group, titanium mesh group and line suturing group, respectively. Bone healing, complications and functional recovery (Paley's method) were observed, the causes of nonunion and delayed union and factors affecting bone healing were analyzed.

RESULTS

There were no significant differences in terms of age, sex, defect length, course, fixation method, defect location and preoperative function of adjacent joints among the 4 groups. All patients were followed up for 12-50 months, with an average of 20.1 months. The clinical healing time of early IM group, late IM group, titanium mesh group and line suturing group were (5.81 ± 0.75) months, (7.56 ± 1.66) months, (7.50 ± 0.70) months and (7.81 ± 1.81) months, respectively, showing significant differences among the 4 groups (P = 0.005). However, only early IM group had significant difference with other groups (P < 0.05), while no significance was found between late IM group and WBR group, between titanium mesh group and suture group (P > 0.05). There were no significant differences in healing ration, complications and functional recovery of adjacent joints among the 4 groups (P > 0.05). There were 4 cases of nonunion and delayed union, all of which were caused by poor quantity or quality of bone graft or unstable bone graft or internal fixation.

CONCLUSION

Both IM technique and WBG technique are effective method for repairing segmental bone defects. In addition to mechanical encapsulation, early IM has biological osteogenesis. However, mechanical encapsulation is a common basis for repairing bone defects, and biological osteogenesis can enhance bone healing.

Intramedullary Nails Yield Superior Results Compared With Plate Fixation When Using the Masquelet Technique in the Femur and Tibia

OBJECTIVES

To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique.

DESIGN

Retrospective cohort study.

SETTING

Four Level 1 Academic Trauma Centers.

PATIENTS/PARTICIPANTS

All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018.

INTERVENTION

Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks.

MAIN OUTCOME MEASUREMENTS

Time to union, number/reason for reoperations, time to full weight-bearing, and any complications.

RESULTS

One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN."

CONCLUSIONS

This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique.

LEVEL OF EVIDENCE

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

Application of multiple wrapped cancellous bone graft methods for treatment of segmental bone defects

BACKGROUND

The aims of this study were to discuss the principle, therapeutic effect and influencing factors of multiple wrapped cancellous bone graft methods for treatment of segmental bone defects.

METHODS

This study retrospectively analyzed the therapeutic effect of different wrapped autologous cancellous bone graft techniques on 51 patients aged (34.5 ± 11.5) years with segmental bone defects. Cancellous bones were wrapped with titanium mesh (n = 9), line mesh (n = 10), line suturing or line binding cortical block, (n = 13), or induced membrane (n = 19). The bone defeats were as follows: tibia (n = 23), radial bone (n = 10), humerus (n = 8), ulnar bone (n = 7), and femur (n = 3). The defect lengths were (5.9 ± 1.1) cm. The functionary recovery of adjacent joint was evaluated by the Paley's method and DASH, respectively.

RESULTS

The incision healed by first intention in 48 cases and secondary healing in 3 cases. All patients were followed up for 19.1 ± 7.1 (12-48) months. Other than one patient with nonunion who received a secondary bone graft, all the patients were first intention of bone healing (the healing rate was 98.0%). The healing time was 6.1 ± 2.1 (3-15) months. There were no significant differences in the healing time among the 4 groups (χ² = 1.864, P = 0.601). The incidence of complications in the grafted site was 11.8%, whereas it was 21.6% in the harvest site. At the last follow-up, all the patients had recovered and were able to engage in weight-bearing activities. The functional recovery was good to excellent in 78.4% of cases, there were no significant difference among the 4 groups (χ² = 5.429, P = 0.143).

CONCLUSIONS

Wrapped cancellous bone grafting is a modified free bone graft method that can be used in the treatment of small and large segmental bone defects as it prevents loosening and bone absorption after bone grafting. The effect of bone healing is related with the quality and quantity of grafted bone, stability of bone defects, property of wrapping material and peripheral blood supply.

Bone Grafting in Total Wrist Arthrodesis With Large Bone Defects Using the Reamer-Irrigator-Aspirator: A Case Study of 2 Patients

Total wrist arthrodesis, fusion of the carpus to the radius, is a well-established and commonly performed procedure for the management of pancarpal degenerative arthritis, trauma, and other severe diseases of the wrist. A well-known complication of this is radiocarpal nonunion, with a rate of 4.4%. Commonly, bone grafting is done at the time of the surgery using local bone, iliac crest bone graft, or cancellous allograft bone. The Synthes Reamer-Irrigator-Aspirator (RIA) is a flexible reamer originally designed as a single-pass intramedullary reamer that can be used in reaming of long bone fractures prior to insertion of an intramedullary nail. Recently, its use has been expanding to the harvesting of bone graft. We present a case study of 2 patients who had total wrist arthrodesis after severe trauma to the wrist resulting in severe bone loss, in whom we used an RIA to obtain bone graft, and both patients went on to union. The first patient is a 17-year-old male who sustained a blast injury from a firework resulting in a mangling injury to the wrist with soft tissue and severe bone loss of his carpus. After being treated with multiple debridements with an external fixator, he was definitively treated with a wrist fusion with RIA bone graft. He went on to osseous union by his 4-month follow-up. Our second patient is a 53-year-old woman who sustained a gunshot wound to the wrist resulting in massive bone loss of the distal radius. After being initially treated with multiple debridements and external fixation, she was treated with a wrist fusion with RIA bone graft and went on to osseous fusion by her 3-month follow-up. Neither patient had complications from the RIA procedure.

The Reamer-Irrigator-Aspirator in Nonunion Surgery

The reamer-irrigator-aspirator (RIA) autograft provides large volumes of autogenous graft that exhibit excellent osteogenic, osteoinductive, and osteoconductive properties. These features, combined with the relative ease of graft harvest and low donor site morbidity when compared with the gold standard iliac crest bone graft (ICBG), have made RIA autograft a viable alternative to ICBG. Some suggest RIA autograft is superior to ICBG, particularly in the setting of large segmental bone defects managed with the induced membrane technique. Although significant complications such as fracture and cortical perforation have been reported, they are preventable if proper surgical strategy and tactics are used.

Can the Reamer/Irrigator/Aspirator System replace anterior iliac crest grafting when treating long bone nonunion?

INTRODUCTION

Autologous bone graft is the gold standard for filling bone defects associated with diaphyseal nonunions. It is typically harvested from the anterior iliac crest (AIC) despite the high complication rate. The Reamer/Irrigator/Aspirator System (RIA) was developed to recover the reaming aspirate and use it as autograft. Initially described for harvesting bone from the femur, the bone volume available is similar to the AIC site; however, its use directly at nonunion sites has been studied very little.

HYPOTHESES

Compared to AIC harvesting, RIA at a non-union site will result in (1) sufficient bone volume, (2) similar time to union and union rate, (3) lower morbidity.

RESULTS

Two groups of patients received an autograft for aseptic nonunion of the tibia or femur for a bone defect up to 2cm: the RIA group (n=30) was followed prospectively and received an autograft by RIA while the AIC group (n=29) was reviewed retrospectively and received an autograft by AIC. We compared the time to union and union rate, operative time, intake of analgesics, duration of hospital stay and complication rate between groups. The RIA provided sufficient bone, 60cm³ on average in a reliable manner. The union rate was similar between groups: 90% (RIA) and 89.7% (CIA) (p=0.965), while the time to union was shorter in the RIA group (8.63±1.47months vs. 10.08±1.7 months) (p=0.006). The operative time (p<0.0001), analgesic intake (p=0.013), length of stay (p<0.0001) and immediate complication rate (p=0.0195) were higher in the AIC group.

DISCUSSION

For the treatment of aseptic long bone nonunion, autograft harvested by the RIA from the nonunion site results in similar union rate and time to union as AIC grafts without additional complications.

LEVEL OF EVIDENCE

IV, comparative retrospective study.

Maximizing outcomes in a Gustilo-Anderson type IIIB open tibia fracture with segmental bone loss: A case report and review of the literature

Introduction

Gustilo-Anderson type IIIB open fractures are severe injuries associated with multiple complications and threaten the viability of the limb. In addition, large segmental bone defects pose reconstructive challenges when treating open fractures and outcomes can be unpredictable. This case report highlights a good outcome in a patient with a type IIIB open tibia fracture with segmental bone loss that was successfully treated with a staged induced membrane technique and latissimus dorsi free flap.

Case Report

A 17-year-old female sustained a Gustilo-Anderson type IIIB open tibia fracture with segmental bone loss after a motor vehicle collision. While amputation seemed inevitable, her extremity was able to be salvaged using the staged induced membrane technique and free flap coverage. She made an exceptional recovery and at 24-month follow-up, her short form-12 scores and foot and ankle outcome scores were close to the average for a healthy adult.

Conclusion

Our patient's outcome represents the benefits of a shared decision-making process with a multidisciplinary approach and highlights the benefit of limb salvage in a healthy patient.

The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A case report

The treatment of open distal tibia fractures remains challenging, particularly when the fracture involves severe soft tissue damage and segmental bone loss. We present the case of a 33-year-old woman who sustained an open distal tibia fracture type 43-A3.3, with segmental bone loss, and a closed bifocal fibular fracture. The fractures were initially fixed with a temporary external fixator. The open distal tibial fracture underwent an intramedullary nailing on day six post-trauma, while the segmental bone loss was refilled with a temporary cement spacer, in order to create a biologic chamber, according to the technique by Masquelet et al. At three months post-trauma, the temporary cement spacer was removed and the bone loss was filled with an autologous bone graft obtained with the Reaming Irrigation Aspiration (RIA) system. The fracture successfully healed at 13 months post-trauma. Masquelet technique, in association with the RIA system, represents a valid strategy in the treatment of non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss.

Managing large bone defects in children: a systematic review of the 'induced membrane technique'

Thirty years after its description by Masquelet in 1986, this is the first systematic review aiming to critically evaluate the 'induced membrane technique' effectiveness in achieving bone union in children. Only six papers fulfilled our inclusion criteria (54 patients). The relatively small number of reported cases did not allow a formal meta-analysis. The tibia was the most involved bone. Most frequent aetiologies were congenital pseudoarthrosis and tumour resections. Although effective in achieving bone healing in ∼91% of the patients (bone defects ≤24 cm long), the induced membrane technique was associated with a high rate of complications (54% of patients).

LEVEL OF EVIDENCE

IV.

Autologous Bone Graft Harvest Using the Reamer-Irrigator-Aspirator

Initially developed to reduce intramedullary pressures during long bone intramedullary nail placement, the reamer-irrigator-aspirator (RIA) can be used to harvest large volume autologous bone graft from the intramedullary canal of a long bone. This case-based surgical technique video demonstrates the appropriate techniques that should be applied while using the RIA to obtain autologous bone graft from the femur. A large volume of bone graft, generally between 30 and 90 cm, can be obtained using a single RIA procedure. The bone graft harvested from the intramedullary canal is excellent regarding its biochemical properties, with several studies reporting higher levels of growth factors and stem cells when compared with iliac crest bone graft. Surgical technique is key to maximize bone graft harvest, as well as to avoid complications including iatrogenic fracture, intraarticular penetration, and fragmentation of either the reamer head from the drive shaft or the guide wire. Pearls and pitfalls regarding sizing of the reamer head, determination of starting point, guide wire placement, reamer advancement, and diligent use of fluoroscopic imaging are highlighted during this video. Finally, outcomes regarding healing of long bone defects when using RIA-derived autologous bone graft and reduction in postoperative pain at the graft donor site are briefly reviewed.

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

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

Combined application of latissimus dorsi myocutaneous flap and iliac bone flap in the treatment of chronic osteomyelitis of the lower extremity

Background

To evaluate the clinical efficacy and safety of latissimus dorsi myocutaneous flap (stage I) combined with iliac bone flap (stage II) in the treatment of chronic osteomyelitis of the lower extremity.

Methods

Clinical data of 18 patients undergoing latissimus dorsi myocutaneous flap in combination with iliac bone flap grafting were retrospectively analyzed. Among them, 2 patients developed chronic osteomyelitis of the lower segment of the femur, 4 were diagnosed with chronic osteomyelitis of the tibial plateau, and 12 with chronic osteomyelitis of the lower segment of the tibia.

Results

All the latissimus dorsi myocutaneous flaps survived in 18 patients. After the corresponding surgery, primary wound healing was achieved in 11 patients, and delayed wound healing was obtained in 7 cases. All wounds were completely healed with postoperative 2 months. Following the iliac bone flap grafting, primary would healing was accomplished in all cases. All dorsal window chambers survived. The bone defects were properly restored within 4–12 postoperative months. Functional training was performed after removal of the internal and external fixators. Postoperative follow-up was endured from 6 months to 10 years. All patients were satisfied with the bone healing and flap texture without the incidence of osteomyelitis and sinus tract. No contraction was observed in the grafting area of 2 patients receiving latissimus dorsi myocutaneous flap grafting. Residual linear scars were noted in the dorsal and iliac donor sites.

Conclusion

Combined usage of stage I latissimus dorsi myocutaneous flap and stage II iliac bone flap grafting is an efficacious and safe surgical technique in clinical practice.

Complications and risk management in the use of the reaming-irrigator-aspirator (RIA) system: RIA is a safe and reliable method in harvesting autologous bone graft

BACKGROUND

Autologous bone grafting (ABG) remains the gold standard for augmentation of bone defects. The RIA system has become more prevalent, but evidence regarding risk management and complications remain scarce. This study presents the risk management and complications associated with RIA in the largest single-center case series to date.

METHODS

All records, operative notes, lab data and radiographs of patients receiving a RIA procedure at Heidelberg´s University Hospital between 01/01/2010 and 31/12/2016 were reviewed. Multivariate logistic regression models adjusting for clinically relevant covariates were used to examine the respective relevance regarding the presence and absence of prolonged postoperative pain (PPP).

RESULTS

A total of 341 RIA procedures on 306 patients were performed at our level-1 trauma center. The femur was the main donor site (98.53%; N = 336) whereas only in 1.47% (N = 5) the tibia was utilized. A total of 11 patients showed a relevant loss of hemoglobin requiring blood transfusion. A total of 22 patients suffered from PPP directly associated with the RIA procedure resulting in prevalence of 6.45%. The 6 major complications in our study were of diverse origin and all intraoperative complications took place in the early phase of the RIA procedure in our center (2010-2013). Our data revealed influence of sex (p = 0.0459) and age (p = 0.0596) on the criterion PPP. The favored model including sex and age resulted in an AUC of 66.2% (CI: 55.5%-76.9%).

CONCLUSION

Perioperative blood loss remains a prevalent complication during RIA reaming. In addition, PPP occurs with a prevalence of 6.45%. This study showed a complication rate of 1.76%, emphasizing RIA´s overall safety and furthermore highlighting the need for vigilance in its application and prior extensive hands-on training of surgeons. Level of Evidence: II.

Salvage of mangled upper extremity using the Masquelet technique in a child: A case report

Aim

To report our experience with the Masquelet concept in a pediatric upper extremity following an open injury to the elbow.

Methods

A case report and literature review.

Results

An 11-year-old boy was transferred to our institution after a motor vehicle collision. There was a primary loss of the ulnohumeral articulation and the surrounding soft tissues as well as the ulnar nerve. Reconstruction used the Masquelet-induced membrane technique and a soft tissue flap. At the 30-month follow-up, the extremity was pain free and functional.

Conclusion

This case highlights the value of the Masquelet technique in pediatric extremity injuries, where there is a loss of a major articular segment, as well as significant soft tissue compromise.

Staged reconstruction of diaphyseal fractures with segmental defects: Surgical and patient-reported outcomes

INTRODUCTION

Two-stage limb reconstruction is an option for patients with critical size segmental bone defects following acute trauma or non-union. Reconstruction is technically demanding and associated with a high complication rate. Current protocols for limb reconstruction have well-documented challenges, and no study has reported on patient outcomes using a validated questionnaire. In this study, we aimed to examine the clinical and patient-centered outcomes following our surgical protocol for two-stage limb reconstruction following critical size segmental defects.

PATIENTS AND METHODS

A single surgeon performed reconstruction of long bone defects using antibiotic impregnated cement spacers and intramedullary cancellous bone autograft. A retrospective chart review was performed. Three reviewers independently measured time to union based on radiographs. The Lower Extremity Functional Scale (LEFS) survey was administered to patients after most recent follow-up.

RESULTS

Ten limbs representing nine patients were included. All patients sustained a lower extremity injury, and one patient had bilateral lower extremity injuries. Average clinical follow-up was 18.3 months (range 7-33) from final surgical intervention, and follow-up to questionnaire administration was 28 months (range 24-37). The mean time between stages was 3.1 months. Average time to unrestricted weight-bearing was 7.9 months from Stage 1 (range 3.4-15.9) and 4.5 months from Stage 2 (range 1.1-11.6). Average time to full union was 16.7 months from Stage 1 (range 6.4-28.6) and 13.5 months from Stage 2 (range 1.8-27). Eight patients (nine limbs) participated in the LEFS survey, the average score was 53.1 (range 30-67), equating to 66% of full functionality (range 38%-84%). Complications included 5 infections, 3 non-unions, and one amputation. There was a moderate positive correlation between infection at any time point and non-union (R=0.65, p=0.03).

DISCUSSION AND CONCLUSIONS

Outcomes in this small patient cohort were good despite risks of complication. There is an association between infection and non-union. Further studies addressing clinical and functional outcomes will help to guide expectations for future surgeons and patients.

Scientific Understanding of the Induced Membrane Technique: Current Status and Future Directions

OBJECTIVES

To review the most recent basic science advances made in relation to the induced membrane technique and how those relate to clinical practice, applications, and future research directions.

DESIGN

Review of the literature.

SETTING

Any trauma center which might encounter large segmental bone defects.

ARTICLES REVIEWED

Basic science articles that looked at characteristics of the induced membrane published in the past 30 years.

INTERVENTION

None.

"Iatrogenic" Segmental Defect: How I Debride High-Energy Open Tibial Fractures

High-energy, open tibial shaft fractures may result in significant comminution, bone loss, and soft tissue injuries. Early, thorough debridement of all nonviable tissue is of critical importance in treating these fractures as an inadequate initial debridement increases the risk of infection and nonunion. Large iatrogenic bone and soft tissue defects can result from debridement and will require subsequent reconstruction by both orthopaedic and plastic surgeons. Although a variety of approaches exist to address these reconstructions, successful management of bone defects remains a considerable challenge. In this article, we detail our approach to debridement and reconstruction of segmental tibial defects and provide a review on the literature on this topic.

Circumferential bone grafting around an absorbable gelatin sponge core reduced the amount of grafted bone in the induced membrane technique for critical-size defects of long bones

OBJECTIVES

The objectives of the study were to introduce a circumferential bone graft around an absorbable gelatin sponge core using an induced membrane technique, to assess its ability to reduce the required amount of graft and to maintain the bone graft, and to evaluate the clinical outcomes in the management of critical-size bone defects.

PATIENTS AND METHODS

Circumferential bone grafting using a staged induced membrane technique for managing critical-size bone defects was performed in 21 patients. Postoperative computed tomography scans were performed 7days after Hemovac drain removal and 3 months after bone grafting. Volumetric measurements of the defect size, gelatin sponge proportion, and amount of grafted bone were performed by two independent observers using three-dimensional (3D) software.

RESULTS

The critical-size defects were located at the metadiaphyseal area of 11 tibias, eight femurs, and two humeri. The average defect size was 8.9cm in length and 65.2cm³ in volume. The absorbable gelatin sponge core replaced 21.4% (average) of the defect volume. There was no significant deterioration in the shape of the grafted bone among the serial 3D models. Eighteen patients (86%) were healed radiographically at 9.1 months (average).

CONCLUSION

Our study suggests that circumferential bone grafting in association with the induced membrane technique could reduce the required amount of bone graft and adequately maintain graft position and shape, with favourable clinical outcomes.

Reamer-Irrigator-Aspirator bone graft harvesting for treatment of segmental bone loss: analysis of defect volume as independent risk factor for failure

INTRODUCTION

The management of segmental bone loss poses a significant clinical challenge. The purpose of this study was to conduct a retrospective evaluation of our experience in treating segmental bone loss, using Reamer-Irrigator-Aspirator (RIA)-harvested autologous bone graft.

MATERIALS AND METHODS

Between June 2008 and March 2015, 81 patients were treated with the RIA technique for multiple purposes. Inclusion criteria for this study were skeletal mature patients with segmental bone loss, due to acute trauma or non-union, who were treated with RIA-harvested bone graft. Exclusion criteria were skeletal immaturity, pathological fractures and indications for the RIA system other than bone graft harvesting. The primary outcome parameter was clinical and radiographical bone healing.

RESULTS

During the study period, 72 patients met the inclusion criteria. In total, 39 patients (54.2%) were classified as having clinical and radiographical bone healing. Although univariate analysis could not reveal any significant influence of specific risk factors to predict the outcome, there was a trend towards statistical significance for defect volume. Further analysis indeed revealed that smaller defect volumes (< 8 cm³) had a lower risk of non-union.

CONCLUSIONS

In approximately half of our study population, the use of the RIA technique for autologous bone graft harvesting in cases of segmental bone loss resulted in a successful outcome with bone healing. Defect size seems to be a critical issue regarding the outcome. Although our results are less promising than previously published, the RIA technique has its place in the treatment algorithm of segmental bone defects.

Extended applications of the reamer-irrigator-aspirator (RIA) system

While the RIA system was initially designed for reaming and clearing the femoral canal contents in preparation for femoral nailing, it has since been used in various other applications in the field of orthopaedic surgery. The RIA is an ideal device for accessing large quantities of autogenous bone graft, to be used in the treatment of nonunions, segmental bone loss, or arthrodesis. The RIA has also been used for treatment of intramedullary infections and osteomyelitis, as well as intramedullary nailing of long bones with metastatic lesions, as it allows for clearing the canal of infectious/tumour burden, and lowers the risk of dissemination into the soft tissues and systemic circulation. There is also some limited evidence that the RIA may be used for clearing the femoral/tibial canal of cement debris. Despite multiple applications, the use of RIA has a risk of eccentric reaming and iatrogenic fractures. RIA is also a costly procedure, and its routine use may not be advantageous in the setting of limited health care resources.

Induced membrane technique using beta-tricalcium phosphate for reconstruction of femoral and tibial segmental bone loss due to infection: technical tips and preliminary clinical results

PURPOSE

This study aimed to provide preliminary evidence regarding effectiveness of grafting beta-tricalcium phosphate (β-TCP) combined with a cancellous autograft for treating nonunion of long bones in the lower extremity due to infection by evaluating clinical and radiological outcomes.

METHODS

We retrospectively reviewed the clinical and radiological results in seven patients (six men, one woman; median age 39 years) treated by the induced membrane technique for nonunion of the femur or tibia due to infection. In the second stage of the procedure, the bony defect was filled with a combination of autologous cancellous bone and β-TCP, which were mixed in approximately the same proportions. The time interval between the second stage of the procedure and bone healing was investigated. Radiographic characteristics including maximum bone gap and radiographic apparent bone gap were evaluated.

RESULTS

The median follow-up period was 14 months. Bone healing was achieved in a median of six months after the second procedure. The median maximum bone gap and radiographic apparent bone gap were 55 mm and 34 mm, respectively.

DISCUSSION

Use of β-TCP, which has osteoconductive ability, with an autograft provided good clinical and radiological outcomes. The findings of this preliminary study suggest the potential of β-TCP as a useful bone substitute for autografts in the induced membrane technique.

CONCLUSIONS

Our findings suggest that β-TCP may be an effective extender when using the induced membrane technique.

Infected tibia defect fractures treated with the Masquelet technique

The treatment after open and infected fractures with extensive soft tissue damage and bone deficit remains a challenging clinical problem. The technique described by Masquelet, using a temporary cement spacer to induce a membrane combined with reconstructive soft tissue coverage, is a possible solution. This study describes the work-up, operative procedure, complications, and the outcome of a homogenous group of patients with an open and infected tibia fracture and segmental bone loss treated with the Masquelet technique (MT).This retrospective study evaluates patients having sustained an open tibia fracture treated with the MT between 2008 and 2013 with a follow up of at least 1 year. The defect was either primary, caused by a high-grade open fracture or secondary due to a non-union after an open fracture. Prerequisite conditions prior to the procedure of the Masquelet were a defect zone with eradicated infection, an intact soft tissue cover and stability provided by an external fixation.Volume of the defect, time until the implantation of the spacer, time of the spacer in situ and the time to clinical and radiological union were evaluated. Patient records were screened for reoperations and complications. The functional clinical outcome was measured.Eight patients were treated with a follow up over 1 year. The spacer was implanted after a median of 11 (2-70) weeks after the accident. The predefined conditions for the Masquelet phase were reached after a median of 12 (7-34) operations.Seven patients required reconstructive soft tissue coverage. The volume of the defect had a median of 111 (53.9-621.6) cm, the spacer was in situ for a median of 12 (7-26) weeks. Radiological healing was achieved in 7 cases after a median time of 52 (26-93) weeks.Full weight bearing was achieved after a median time of 16 (11-24) weeks. Four patients needed a reoperation. The lower limb functional index was a median of 60% (32-92%).Seven out of 8 patients treated in this group of severe open and infected tibia fractures did both clinically and radiologically heal. Due to the massive destruction of the soft tissue, patients needed several reoperations with soft tissue debridements and reconstruction before the spacer and the bone graft could be implanted.

Bone grafting via reamer-irrigator-aspirator for nonunion of open Gustilo-Anderson type III tibial fractures treated with multiplanar external fixator

Introduction: The purpose of this investigation was to evaluate the outcomes following reamer-irrigator-aspirator (RIA) autogenous bone grafting (ABG) of high-grade open tibia fracture nonunions stabilized via multiplanar external fixation.

Methods: We retrospectively reviewed all patients with Gustilo-Anderson type III open tibia fractures treated with multiplanar external fixation and who underwent RIA ABG for nonunion at our institutional Level 1 Trauma Center between 2008 and 2015. All patients between 15 and 65 years of age with a minimum of six-month follow-up were included. The primary outcomes of interest were achievement of union, time to union, and incidence of revision surgery. Complications and all-cause reoperation were recorded as secondary endpoints.

Results: Fifteen patients met the inclusion criteria with a mean age of 41.1 ± 14.0 years. RIA ABG was harvested from the femur in all cases, with a mean volume of 34 ± 15 mL. At an average follow-up of 13.3 ± 6.8 months, all patients achieved union, including two who required repeat RIA ABG. One patient experienced a femoral shaft fracture four months following RIA that required intramedullary fixation. The average time to union was 6.0 ± 6.3 months. Twelve patients (80%) went on to union within six months and 13 (86.7%) within one year. Five patients experienced a total of six post-operative complications including three deep infections, one refracture through the nonunion site, and one gradual varus deformity. Two patients in this series required a subsequent RIA autografting procedure secondary to persistent nonunion despite initial RIA.

Conclusion: We found that RIA ABG offered a reliable solution to nonunion of Gustilo-Anderson type III open tibial fractures treated with multiplanar external fixation, circumventing the need to change the method of fixation.

Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest

OBJECTIVES

To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA).

DESIGN

Retrospective review.

SETTING

Academic Level-I trauma hospital.

PATIENTS

One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis.

INTERVENTION

Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG).

MAIN OUTCOME MEASURE

Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications.

RESULTS

The average Hct drop was found to be 13.7 (4.1-27.4) in the RIA cohort of 61 patients and 7.36 (1.2-14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100-2000 mL) in the RIA cohort compared with 255 mL (50-1000 mL) in the ICBG cohort (P < 0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2-6.3, P < 0.001). RIA procedures collected an average 53 mL (20-100 mL) of bone graft compared with 27 mL (15-50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications.

CONCLUSIONS

This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Putting 3D modelling and 3D printing into practice: virtual surgery and preoperative planning to reconstruct complex post-traumatic skeletal deformities and defects

3D printing technology has revolutionized and gradually transformed manufacturing across a broad spectrum of industries, including healthcare. Nowhere is this more apparent than in orthopaedics with many surgeons already incorporating aspects of 3D modelling and virtual procedures into their routine clinical practice. As a more extreme application, patient-specific 3D printed titanium truss cages represent a novel approach for managing the challenge of segmental bone defects. This review illustrates the potential indications of this innovative technique using 3D printed titanium truss cages in conjunction with the Masquelet technique. These implants are custom designed during a virtual surgical planning session with the combined input of an orthopaedic surgeon, an orthopaedic engineering professional and a biomedical design engineer. The ability to 3D model an identical replica of the original intact bone in a virtual procedure is of vital importance when attempting to precisely reconstruct normal anatomy during the actual procedure. Additionally, other important factors must be considered during the planning procedure, such as the three-dimensional configuration of the implant. Meticulous design is necessary to allow for successful implantation through the planned surgical exposure, while being aware of the constraints imposed by local anatomy and prior implants. This review will attempt to synthesize the current state of the art as well as discuss our personal experience using this promising technique. It will address implant design considerations including the mechanical, anatomical and functional aspects unique to each case.

Masquelet technique: myth or reality? A systematic review and meta-analysis

INTRODUCTION

The induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union.

METHODS

A systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords "Masquelet technique" and "induced membrane technique". Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients' clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data.

RESULTS

Seventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001).

DISCUSSION

IMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis.

CONCLUSION

Further studies are needed to demonstrate the role the patients' clinical features and IMT variants have upon achieving bone union and infection eradication.

Autologous bone graft in the treatment of post-traumatic bone defects: a systematic review and meta-analysis

Background

This meta-analysis aimed to determine the bone union rate of bone defects treated with the different autologous bone graft techniques.

Methods

The PubMed and the Cochrane Library databases were searched using the terms: ‘fracture’ AND (‘bone loss’ OR ‘defect’ OR ‘defects’) AND ‘bone graft’, restricted to English language, to human species, and to a publication period from January 1999 to November 2014. Data were extracted by one of the reviewers and then checked by the second. A quality of evidence score and a methodology score were used. Heterogeneity was assessed. A random effects model approach was used to combine estimates.

Results

Out of 376 selected studies only 34 met the inclusion criteria. The summary pooled union rate was 91 % (95 % CI: 87–95 %) while union rate after additional procedures raised to 98 % (95 % CI 96–99 %). No association between union rate and bone defect size was found. (Univariable regression model: vascularized: P = 0.677; non-vascularized: 0.202. Multivariable regression model: vascularized: P = 0.381; non-vascularized: P = 0.226). Vascularized graft was associated with a lower risk of infection after surgery when compared to non-vascularized graft (95 % CI 0.03 to 0.23, p < 0.001).

Conclusion

The results of this meta-analysis demonstrate the effectiveness of autologous graft for bone defects. Furthermore, from the available clinical evidence bone defect size does not seem to have an impact on bone union when treated with autologous bone graft techniques.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1312-4) contains supplementary material, which is available to authorized users.

Lower Extremity Limb Salvage: Lessons Learned From 14 Years at War

American survivability during the current conflicts in Iraq and Afghanistan continues to improve, though the rate of extremity injury remains quite high. The decision to proceed with amputation versus limb salvage remains controversial. Exposure to combat wound with severe high-energy lower extremity trauma during the previous 14 years at war has incited important advances in limb salvage technique and rehabilitation.