Induced membrane technique for clavicle reconstruction in paediatric patients: Report of four cases

Satisfactory results in five patients with septic clavicle nonunion using the modified Masquelet technique and structural iliac crest autograft

Background

Indications for clavicle fracture fixation have increased dramatically over the last 20 years. Chronic surgical site infection is a particularly severe complication arising from this procedure and can induce nonunion and clinical disability. In such cases, the modified Masquelet technique using an iliac crest autograft (cancellous or tricortical) enables treatment of any bone infection as well as reconstruction of the segmental defect. The aim of this study was to analyze the clinical and radiological results of this procedure at mid-term follow-up.

Methods

In this monocentric retrospective study, patients suffering from a septic clavicle nonunion were treated with a modified Masquelet technique and reviewed at a minimum follow-up point of two years. They were clinically assessed using active range of motion, pain score (visual analog scale 0 to 10), Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder value score. Bone healing was measured using standard X-rays and CT scans.

Results

Five patients were included (mean age 49 years; range 30 to 62). C. acnes was involved in 80% (n = 4) of these cases. Following the first stage of treatment, the mean bone defect was 3.4 cm (range 2.6 to 6.4 cm). The second stage, performed at a minimum of six weeks (mean 7 ± 1 weeks), used an iliac crest bone autograft in all cases. At a mean follow-up of 5 ± 3 years, the mean pain score was 0.3/10 points (0 to 1), the mean Constant score was 86 points (78 to 96), the mean American Shoulder and Elbow Surgeons score was 98 ± 2%, and the subjective shoulder value score 91 ± 11%, with two "forgotten shoulders" out of five. On CT scan analysis, bone healing was achieved in 100% of cases. One plate (20%) was removed one year following the procedure due to the patient's discomfort; pain and discomfort at the iliac crest site were reported in 5/5 (100%) patients.

Conclusion

The modified Masquelet technique using an iliac crest autograft is a reliable and effective technique for treating septic nonunion of the clavicle. It both treats the bony defect and eradicates infection when conducted in association with débridement and antibiotics. In the five cases reported here, this approach had satisfactory results, both subjectively and objectively, with a very low reoperation rate despite persistent pain from iliac bone harvesting.

Delayed Reconstruction of the Perforator Pedicle Propeller Flap after the Induced Membrane Technique for Gustilo IIIB Open Distal Tibial Fracture

This study aimed to evaluate the safety and efficacy of delayed reconstruction of the perforator pedicle propeller flap after the induced membrane technique in the treatment of Gustilo IIIB open distal tibial fracture, and to evaluate the clinical outcome and complications of two different perforator pedicle propeller flaps.Thirty-four patients with Gustilo IIIB open distal tibial fractures treated by the induced membrane technique and delayed reconstruction of two different perforator pedicle propeller flaps from May 2017 to March 2022 were retrospectively analyzed. Patients were divided into two groups according to the different kinds of perforator pedicle propeller flaps covered. The operation required two stages. The Radiographic Union Score for Tibial fractures (RUST) was used to evaluate the healing of the tibial bone defect. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to evaluate ankle function. The complications associated with the technique were recorded.The number of serial debridements, excluding those performed during emergency and final operations, was a mean of 2.28 ± 0.83 in the PAPF group. The PAPF group had a mean bone defect length of 6.76 ± 0.69 cm, the median healing time of 13.11 ± 0.96 months, RUST score 12.68 ± 1.63, and AOFAS score of 84.12 ± 6.38. On the other hand the PTAPF group's mean bone defect length was 6.73 ± 0.95 cm, the median healing time 12.63 ± 1.46 months, RUST score 13.73 ± 1.53 and AOFAS score 82.79 ± 5.49. There were no observed significant differences the two groups in the number of serial debridements, bone defect length, bone union time, RUST score, or AOFAS score (p > 0.05). Flap size ranged from 9 × 6 cm2 to 14 × 7 cm2 in the PAPF group and from 9 × 6 cm2 to 13 × 7 cm2 in the PTAPF group. There were no severe complications such as flap-related complications or amputation. The differences in complications in the two groups were not statistically significant.In cases of severe open tibial fracture, the reconstructive method is important. When delayed reconstruction is inevitable, surgeons should first perform radical debridement, followed by vacuum sealing drainage as a bridging therapy; both PAPF and PTAPF can be considered for definitive soft tissue coverage.

Questions about Using the Induced Membrane Technique to Manage Cases of Congenital Tibial Pseudarthrosis

The induced membrane technique is an innovative approach for repairing critical bone defects and has been applied recently in patients with congenital pseudarthrosis of the tibia (CPT). CPT is frequently associated with neurofibromatosis type 1 (NF1). Here, we briefly describe the clinical results of the induced membrane technique in NF1-deficient patients with CPT and in an animal model of CPT. Furthermore, we discuss the hypotheses used to explain inconsistent outcomes for the induced membrane technique in CPT-especially when associated with NF1.

Congenital pseudarthrosis of the clavicle: a systematic review

PURPOSE

There is no consensus on the type of surgical treatment of congenital pseudarthrosis of the clavicle due to its rarity. The purpose of this study is to provide evidence in favor of a surgical technique and to explore factors correlated with bone consolidation.

METHODS

Systematic review of the literature and an analysis of the data for each subject, including all available subjects from the published series and clinical cases since 1990. Fisher's exact tests or T-tests were used to evaluate the effect of independent variables (age at surgery and type of treatment) on bone healing.

RESULTS

The literature search provides 305 articles; 30 were selected, reporting 191 patients and 194 clavicles. One hundred and fifty-one clavicles were operated on at a mean age of nine years and four months (from 8 months to 21 years). Thirteen clavicles (8, 6%) had not consolidated at the last follow-up. Concerning the type of fixation, the rate of healing was similar for plates and pins (p = 0.27). The rate of consolidation was higher with autograft than with allograft, xenograft, or no graft (p = 0.00001), and was 100% for vascularized graft. The mean age at surgery was higher for patients who healed at the last follow-up (118 vs. 61 months, p = 0.001).

CONCLUSION

In the event of surgical indication for congenital pseudarthrosis of the clavicle, it is recommended to perform autograft and stable fixation (level 4) after seven years old (level 4).

Congenital Pseudarthrosis of the Clavicle in Children: A Systematic Review

(1) Background: Congenital pseudoarthrosis of the clavicle is a rare condition due to the failure of the union process of the ossification nuclei of the clavicle. The aim of this study was to conduct a systematic review of relevant case series about the argument to find an up-to-date base of evidence for treatment choice. (2) Methods: an electronic literature research of Ovid, MEDLINE and the Cochrane Library databases was conducted, and articles were selected based on inclusion criteria. Demographic data, clinical features, treatment options, outcomes and complications were analyzed. (3) Results: 21 articles met the inclusion criteria, showing a poor overall study quality; 231 pediatric patients (240 clavicles) were analyzed. The condition was typically right sided, showed no sex predominance and no clear predisposing factors. 156 patients underwent surgical treatment, mainly open debridement and refresh of bony ends, fixation with pin or plate and bone graft, with a successful union rate of 87.4%. The nonunion rate was significantly higher in the allograft group (44.4%, p = 0.019). (4) Conclusions: this paper presents an updated systematic review about treatment of congenital pseudoarthrosis of the clavicle. We confirm the generally satisfactory results of surgery, demonstrating that successful union is achievable in 87.4% of cases with a prevalence of 15.7% of major complications. Nonetheless our results should be interpreted with caution due to several limitations.

Surgical Management of Congenital Pseudoarthrosis of the Clavicle: A Review of Current Concepts

Nowadays, surgical intervention is an accepted treatment for congenital pseudoarthrosis of the clavicle (CPC). The purpose of this literature review is to evaluate the current body of evidence for methods and outcomes of surgical intervention for CPC. CPC is a rare deformity of the middle third of the clavicle not often identified until three to five years of age, at which time surgery is often recommended. The most common indication for surgery is cosmetic appearance, but other indications include pain, shoulder dysfunction, and prevention of complications later in life. Surgical intervention involves the resection and excision of the pseudoarthrosis, bone grafting (most commonly autologous tissue from the iliac crest), and internal fixation using plates or Kirschner wires (K-wires). Plate fixation tends to have fewer complications and better long-term outcomes. Following surgery, outcomes include satisfaction with cosmetic appearance, decreased pain, and improved shoulder function.

The Basic Science Behind the Clinical Success of the Induced Membrane Technique for Critical-Sized Bone Defects

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The induced membrane technique (IMT) takes advantage of an osteoinductive environment that is created by the placement of a cement spacer into a bone defect.

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Most commonly, a polymethylmethacrylate (PMMA) spacer has been used, but spacers made from other materials have emerged and achieved good clinical outcomes.

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The IMT has demonstrated good results for long-bone repair; however, more research is required in order to optimize union rates as well as delineate more precise indications and surgical timing.

Congenital pseudarthrosis of the forearm treated with induced membrane technique: A case report

Congenital pseudarthrosis of the forearm (CPF) is an uncommon entity frequently described in association with neurofibromatosis type 1. Surgical treatment Is required. This is a challenging pathology in pediatric orthopedic surgery due to the difficulty of achieving a satisfying result in terms of bone defect healing. Many techniques are described such us free vascularized fibula, illizarov and induced membrane. We describe a first case of the forearm non union associated with neurofibromatosis type 1 successfully treated with 2 steps of induced membrane. Whatever the technique selected it's remain challenging problem in pediatric orthopaedic.