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Schaffler BC, Konda SR. Tibial bone loss. OTA Int 2024; 7:e315. [PMID: 38840708 PMCID: PMC11149745 DOI: 10.1097/oi9.0000000000000315] [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: 11/19/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 06/07/2024]
Abstract
Critical bone loss after open fractures, while relatively uncommon, occurs most frequently in high-energy injuries. Fractures of the tibia account for the majority of open fractures with significant bone loss. A number of different surgical strategies exist for treatment of tibial bone loss, all with different advantages and disadvantages. Care should be taken by the surgeon to review appropriate indications and all relevant evidence before selecting a strategy.
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Affiliation(s)
| | - Sanjit R. Konda
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
- Jamaica Hospital Medical Center, Queens, NY
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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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Wang K, Zhou M, Zhang Y, Jin Y, Xue Y, Mao D, Rui Y. Fibromodulin facilitates the osteogenic effect of Masquelet's induced membrane by inhibiting the TGF-β/SMAD signaling pathway. Biomater Sci 2024; 12:1898-1913. [PMID: 38426394 DOI: 10.1039/d3bm01665j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Masquelet's induced membrane (IM) technique is a promising treatment strategy for the repair of substantial bone defects. The formation of an IM around polymethylmethacrylate bone cement plays a crucial role in this technique. Several studies have indicated that IMs have bioactivity because they contain abundant blood vessels, a variety of cells, and biological factors. The bioactivity of an IM increases during the initial stages of formation, thereby facilitating bone regeneration and remodeling. Nevertheless, the precise mechanisms underlying the enhancement of IM bioactivity and the promotion of bone regeneration necessitate further investigation. In this study, we successfully developed a Masquelet IM model of critical femur defects in rats. By employing proteomics analysis and biological detection techniques, we identified fibromodulin (FMOD) as a pivotal factor contributing to angiogenesis and the enhanced bioactivity of the IM. A significant increase in angiogenesis and the expression of bioactive factors in the IM was also observed with the upregulation of FMOD expression. Furthermore, this effect is mediated through the inhibition of the transforming growth factor beta (TGF-β)/SMAD signaling pathway. We also demonstrated that administering recombinant human FMOD enhanced osteogenesis in rat bone marrow mesenchymal stem cells and angiogenesis in human umbilical vein endothelial cells in vitro. Furthermore, the negative regulatory effect of the TGF-β signaling pathway was verified. In conclusion, this study provides a novel theoretical basis for the application of IMs in bone-defect reconstruction and explores possible new mechanisms that may play an important role in promoting the bioactivity and osteogenic potential of IMs.
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Affiliation(s)
- Kai Wang
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
- Suzhou Medical College of Soochow University, Suzhou, 215031, China
| | - Ming Zhou
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
- Suzhou Medical College of Soochow University, Suzhou, 215031, China
| | - Yuanshu Zhang
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
| | - Yesheng Jin
- Suzhou Medical College of Soochow University, Suzhou, 215031, China
| | - Yuan Xue
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
| | - Dong Mao
- Orthopaedic Institute, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Yongjun Rui
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
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Guimarães JAM, Scorza BJB, Machado JAP, Cavalcanti ADS, Duarte MEL. Characterization of the Masquelet Induced Membrane Technique in a Murine Segmental Bone Defect Model. Rev Bras Ortop 2023; 58:e798-e807. [PMID: 37908532 PMCID: PMC10615599 DOI: 10.1055/s-0043-1771490] [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: 09/23/2022] [Accepted: 12/16/2022] [Indexed: 11/02/2023] Open
Abstract
Objective To reproduce in an animal model the surgical technique of Masquelet used in the treatment of critical bone defects and to analyze the characteristics of the membrane formed around the bone cement. Methods A 10mm critical defect was created in the femoral shaft of 21 Sprague-Dawley rats. After resection of the central portion of the diaphysis, the defect was stabilized with a Kirschner wire introduced through the medullary canal and with the interposition of a bone cement spacer. After 2, 4, and 6 weeks of the surgical procedure, the animals were euthanized and evaluated on radiographs of the posterior limb regarding the size of the defect, alignment and stability of the osteosynthesis. The membranes formed around the spacer were subjected to histological analysis to assess thickness, connective tissue maturation and vascular density. Results Over time, the membranes initially made up of loose connective tissue were replaced by membranes represented by dense connective tissue, rich in thick collagen fibers. At six weeks, membrane thickness was greater (565 ± 208μm) than at four (186.9 ± 70.21μm, p = 0.0002) and two weeks (252.2 ± 55.1μm, p = 0.001). All membranes from the initial time showed foci of osteogenic differentiation that progressively reduced over time. Conclusion In addition to the structural and protective function of the membrane, its intrinsic biological characteristics can actively contribute to bone regeneration. The biological activity attributed by the presence of foci of osteogenesis confers to the membrane the potential of osteoinduction that favors the local conditions for the integration of the bone graft.
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Affiliation(s)
| | - Breno Jorge Braga Scorza
- Coordenador de pós-graduação, Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brasil
| | - Jamila Alessandra Perini Machado
- Coordenador de pós-graduação, Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brasil
- Pesquisadora, Laboratório de Pesquisa de Ciências Farmacêuticas, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brasil
| | | | - Maria Eugênia Leite Duarte
- Coordenador de pós-graduação, Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brasil
- Cirurgião ortopédico, Instituto D'Or de Ensino e Pesquisa, IDOR, Rio de Janeiro, RJ, Brasil
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Thakeb MF, Kozman MA, ElGebeily MA, Baraka MM, Al Kersh MA. Bone Transport Through Induced Membrane Versus Conventional Bone Transport in Management of Infected Long-Bone Defects of Lower Limbs: A Randomized Controlled Trial. J Orthop Trauma 2023; 37:462-468. [PMID: 37074808 DOI: 10.1097/bot.0000000000002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To compare bone transport through induced membrane (BTM) and conventional bone transport (BT) regarding docking site union and infection recurrence in the management of infected long-bone defects. DESIGN Prospective, randomized, controlled study. SETTING Tertiary-level center. PARTICIPANTS Thirty patients with infected nonunited long-bone fractures of lower limbs were included. INTERVENTION Fifteen patients were treated by BTM in group A, and 15 patients were treated by BT in group B. OUTCOME MEASUREMENTS The outcome measures were external fixation time, external fixation index, and docking time. Bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov scoring system. Postoperative complications were evaluated according to the Paley classification. RESULTS The mean docking time was significantly lower in the BTM group than in the BT group (3.6 ± 0.82 months vs. 4.8 ± 0.86 months, respectively; P value 0.001). Docking site nonunion and infection recurrence were significantly lower in the BTM group than in the BT group (0% vs. 40%; P value 0.02 and 0% vs. 33.3%; P value 0.04, respectively), with no significant difference in the external fixation index ( P value 0.08). CONCLUSIONS This is the first prospective, randomized, controlled study comparing BTM and BT techniques, showing that BTM had significantly faster docking site union, lower incidence of postoperative complications including docking site nonunion and infection recurrence rates, and lower number of additional procedures needed at the expense of 2-staged operation in comparison with BT. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mootaz F Thakeb
- Division of Limb Reconstruction Surgery, Department of Orthopedic Surgery, Faculty of Medicine, Ain-Shams University, Abbasia, Cairo, Egypt
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Takase K, Fukui T, Oe K, Sawauchi K, Yoshikawa R, Yamamoto Y, Hayashi S, Matsumoto T, Kuroda R, Niikura T. Effect of low-intensity pulsed ultrasound on osteogenic differentiation of human induced membrane-derived cells in Masquelet technique. Injury 2023:S0020-1383(23)00343-1. [PMID: 37062672 DOI: 10.1016/j.injury.2023.04.004] [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: 01/24/2023] [Revised: 03/02/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION The Masquelet technique is a relatively new method for large bone defect treatment. In this technique, grafted bone tissue is used, and after the cement is removed, the induced membrane (IM; that form around the cement spacers placed in the bone defect region) is thought to play an important role in promoting bone formation. On the other hand, low-intensity pulsed ultrasound (LIPUS) is known to promote fracture healing and angiogenesis through mechanical stimulation. This study aimed to investigate the in vitro effects of LIPUS on the osteogenic differentiation of human induced membrane-derived cells (IMCs). METHODS Seven patients who had been treated using the Masquelet technique were enrolled. The IM was harvested during the second stage of the technique. IMCs were isolated, cultured in growth medium, and then divided into two groups: (1) control group, IMCs cultured in osteogenic medium without LIPUS, and (2) LIPUS group, IMCs cultured in osteogenic medium with LIPUS treatment. Adherent cells from the IM samples were harvested after the first passage and evaluated for cell surface protein expression using immunostaining. A cell proliferation assay was used to count the number of IMCs using a hemocytometer. Osteogenic differentiation capability was assessed using an alkaline phosphatase (ALP) activity assay, Alizarin Red S staining, and real-time reverse transcription-polymerase chain reaction. RESULTS Cell surface antigen profiling revealed that the IMCs contained cells positive for the mesenchymal stem cell-related markers CD73, CD90, and CD105. No significant difference in cell numbers was found between the control and LIPUS groups. The ALP activity of IMCs in the LIPUS group was significantly higher than that in the control group on days 7 and 14. Alizarin red S staining intensity was significantly higher in the LIPUS group than in the control group on day 21. Runx2 and VEGF expression was significantly upregulated on days 7 and 14, respectively, compared with levels in the control group. CONCLUSION We demonstrated the significant effect of LIPUS on the osteogenic differentiation of human IMCs. This study indicates that LIPUS can be used as an additional tool for the enhancement of the healing process of the Masquelet technique.
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Affiliation(s)
- Kyohei Takase
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Kenichi Sawauchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Ryo Yoshikawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Yuya Yamamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9 Rokutanji-cho, Nishinomiya 662-0918, Japan.
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Cai L, Hong Z, Zhang Y, Xiang G, Luo P, Gao W, Li Z, Zhou F. Management of wounds with exposed bone structures using an induced-membrane followed by polymethyl methacrylate and second-stage skin grafting in the elderly with a 3-year follow-up. Int Wound J 2023; 20:1020-1032. [PMID: 36184261 PMCID: PMC10031252 DOI: 10.1111/iwj.13955] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022] Open
Abstract
The treatment of traumatic wounds with exposed bone or tendons is often challenging. An induced membrane (IM) is used to reconstruct bone defects, as it provides an effective and sufficient blood supply for bone and soft-tissue reconstruction. This study explored a novel two-stage strategy for wound management, consisting of initial wound coverage with polymethyl methacrylate (PMMA) and an autologous split-thickness skin graft under the IM. Fifty inpatients were enrolled from December 2016 to December 2019. Each patient underwent reconstruction according to a two-stage process. In the first stage, the defect area was thoroughly debrided, and the freshly treated wound was then covered using PMMA cement. After 4-6 weeks, during the second stage, the PMMA cement was removed to reveal an IM covering the exposed bone and tendon. An autologous split-thickness skin graft was then performed. Haematoxylin and eosin (H&E) staining and immunohistochemical analysis of vascular endothelial growth factor (VEGF), CD31 and CD34 were used to evaluate the IM and compare it with the normal periosteal membrane (PM). The psychological status and the Lower Extremity Function Scale (LEFS) as well as any complications were recorded at follow-up. We found that all skin grafts survived and evidenced no necrosis or infection. H&E staining revealed vascularised tissue in the IM, and immunohistochemistry showed a larger number of VEGF-, CD31- and CD34-positive cells in the IM than in the normal PM. The duration of healing in the group was 5.40 ± 1.32 months with a mean number of debridement procedures of 1.92 ± 0.60. There were two patients with reulceration in the group. The self-rating anxiety scale scores ranged from 35 to 60 (mean 48.02 ± 8.12). Postoperatively, the LEFS score was 50.10 ± 9.77. Finally, our strategy for the management of a non-healing wound in the lower extremities, consisting of an IM in combination with skin grafting, was effective, especially in cases in which bony structures were exposed in the elderly. The morbidity rate was low.
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Affiliation(s)
- Leyi Cai
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Zipu Hong
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Yingying Zhang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Guangheng Xiang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Peng Luo
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Weiyang Gao
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Zhijie Li
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Feiya Zhou
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
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Lu W, Zhao R, Fan X, Wang H, Zeng M. Time-varying characteristics of the induced membrane and its effects on bone defect repair. Injury 2023; 54:318-328. [PMID: 36581479 DOI: 10.1016/j.injury.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/17/2022] [Accepted: 12/23/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE This study intended to determine the properties of induced membranes after various periods of polymethyl methacrylate (PMMA) retention and the effect of different retention intervals on subsequent defect repair. METHODS Model of a critical bone defect in rabbits was prepared to obtain the induced membrane. For varying intervals of spacer insertion (2, 4, 6, 8, 12, 16, and 20 weeks postoperatively), angiogenesis, osteogenesis, and MSC-related properties were analyzed by immunohistochemistry and western-blot. Furthermore, 2, 4, 6, and 8 weeks after PMMA insertion, bone grafting was performed. Characteristics of defect repair were analyzed by X-ray and micro-CT analysis. RESULTS The induced membrane displayed angiogenesis, osteogenesis, and MSC-related properties from the 2- to 20-week intervals. Quantitation of protein expression (RUNX2, ALP, VEGF, TGF-beta, OCT4, and STRO1) revealed that selected proteins gradually rose to a high level at 4-8 weeks postoperatively and then decreased to a low level over a long time period. Following bone grafting, the most new bone formation was in the group when grafting was performed at 4 weeks, followed by the groups at 2 and 6 weeks, with the least in the group at 8 weeks. CONCLUSION The induced membrane displays angiogenesis, osteogenesis, and MSC-related properties from the 2- to 20-week intervals. These were increased to a peak level at 4-8 weeks postoperatively and then gradually decreased. The optimal timing for bone grafting at the second stage in the presented model was 4 weeks after PMMA insertion.
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Affiliation(s)
- Wei Lu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Ruibo Zhao
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Xiaolei Fan
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Haoyi Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Min Zeng
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan 410008, China.
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Li D, Zhao D, Zeng Z, Huang F, Jiang Z, Xiong H, Guan T, Fang B, Li Y. Ternary regulation mechanism of Rhizoma drynariae total flavonoids on induced membrane formation and bone remodeling in Masquelet technique. PLoS One 2022; 17:e0278688. [PMID: 36473008 PMCID: PMC9725127 DOI: 10.1371/journal.pone.0278688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
CONTEXT Rhizoma drynariae total flavonoids (RDTF) are used to treat fractures. CD31hiEmcnhi vessels induced by PDGF-BB secreted by osteoclast precursors, together with osteoblasts and osteoclasts, constitute the ternary regulatory mechanism of bone tissue reconstruction. OBJECTIVE This study aimed to determine whether RDTF can promote bone tissue remodeling and induce membrane growth in the rat Masquelet model and to explore its molecular mechanism based on the ternary regulation theory. METHODS Thirty-six SD rats were randomized to three groups: blank, induced membrane, and RDTF treatment (n = 12/group). The gross morphological characteristics of the new bone tissue were observed after 6 weeks. Sixty SD rats were also randomized to five groups: blank, induction membrane, low-dose RDTF, medium-dose RDTF, and high-dose RDTF (n = 12/group). After 4 weeks, immunohistochemistry and western blot were used to detect the expression of membrane tissue-related proteins. The mRNA expression of key factors of ternary regulation was analyzed by qRT-PCR. RESULTS RDTF positively affected angiogenesis and bone tissue reconstruction in the bone defect area. RDTF could upregulate the expression of key factors (PDGF-BB, CD31, and endomucin), VEGF, and HMGB1 mRNA and proteins in the ternary regulation pathway. DISCUSSION AND CONCLUSION Although the expected CD31hiEmcnhi vessels in the induction membrane were not observed, this study confirmed that RDTF could promote the secretion of angiogenic factors in the induced membrane. The specific mechanisms still need to be further studied.
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Affiliation(s)
- Ding Li
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dun Zhao
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhikui Zeng
- Department of Orthopedics, The Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, China
| | - Feng Huang
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziwei Jiang
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hao Xiong
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tianan Guan
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bin Fang
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yue Li
- Department of Orthopedic, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Liu X, Yang J, Wang H, Lu S, Fan C, Wen G. Simultaneous reconstruction of septic composite defects in lower extremities: Combination of fasciocutaneous perforator flap and Masquelet technique. Front Surg 2022; 9:900796. [PMID: 36090325 PMCID: PMC9454341 DOI: 10.3389/fsurg.2022.900796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background Management of composite defects with deep infection is a challenge to reconstructive surgeons. This study aimed to demonstrate the versatility, safety, and complications of simultaneous reconstruction of infectious composite defects with fasciocutaneous perforator flap combined with the Masquelet technique. Methods This study presents 10 patients in whom a fasciocutaneous perforator flap combined with the Masquelet technique was used to restore soft tissue and bone defects of the lower extremity, and were admitted in two level 1 trauma centers in Shanghai. The first stage included debridement of necrotic bone and infected tissues, implantation of a polymethylmethacrylate cement spacer to cover the void; bridging fixation of the osseous defect using external or internal fixators, and soft-tissue reconstruction with a fasciocutaneous perforator flap. The second stage included cement spacer removal with membrane preservation, refreshing bone edges, and grafting the cavity with bone morphogenetic proteins and autologous iliac bone graft. Results The mean follow-up duration after autologous bone graft was 17.5 months. The average bony defects and average flap dimensions were 7.1 cm and 44.9 cm2, respectively. All flaps survived uneventfully. No recurrence of infection was detected in either the second stage of surgery or follow-up period. The mean duration of bone consolidation was 31.9 weeks. One patient had a 2 cm leg length discrepancy, and one patient had mild foot drop. No residual deformity requiring a secondary procedure occurred. Conclusion Fasciocutaneous perforator flap combined with Masquelet technique provides a reliable and versatile alternative for patients with composite defects resulting from lower extremity infection.
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Affiliation(s)
- Xuanzhe Liu
- Shanghai Jiao Tong University affiliated Sixth People’s Hospital
| | - Jin Yang
- First Affiliated Hospital of Kunming Medical University
| | - Hongshu Wang
- Shanghai Jiao Tong University affiliated Sixth People’s Hospital
| | - Shengdi Lu
- Shanghai Jiao Tong University affiliated Sixth People’s Hospital
| | - Cunyi Fan
- Shanghai Jiao Tong University affiliated Sixth People’s Hospital
- Correspondence: Cunyi Fan Gen Wen
| | - Gen Wen
- Shanghai Jiao Tong University affiliated Sixth People’s Hospital
- Correspondence: Cunyi Fan Gen Wen
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Hamiti Y, Yushan M, Yalikun A, Lu C, Yusufu A. Matched comparative study of trifocal bone transport versus induced membrane followed by trifocal bone transport in the treatment of segmental tibial defects caused by posttraumatic osteomyelitis. BMC Musculoskelet Disord 2022; 23:572. [PMID: 35701789 PMCID: PMC9195234 DOI: 10.1186/s12891-022-05501-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/30/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives To compare the efficacy and clinical outcomes of trifocal bone transport (TBT) versus induced membrane followed by trifocal bone transport (IM + TBT) in the treatment of tibial defects > 6 cm caused by posttraumatic osteomyelitis. Methods A total of 69 eligible patients with tibial defects > 6 cm who were treated between January 2010 and January 2018 were retrospectively reviewed. Overall, 18 patients treated by IM + TBT and 18 treated by TBT were matched by propensity score analysis. The mean tibial defect after radical debridement was 6.97 ± 0.76 cm (range, 6.0 to 8.9 cm). The measurements, including demographic data, external fixation index (EFI), external fixation time (EFT), duration of docking union, bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification during follow-up were recorded. Results Age, gender, injury mechanism, affected side, defect size, previous operation time, and follow-up time were not significantly different between the two groups (P > 0.05). The mean EFT was 293.8 ± 12.1 days in the TBT group vs. 287.5 ± 15.3 days in the IM + TBT group. The mean EFI was 36.02 ± 2.76 days/cm vs. 34.69 ± 2.83 days/cm, respectively. The mean duration of docking union was 210.7 ± 33.6 days vs. 179.7 ± 22.9 days, respectively. There was no significant difference in postoperative bone and functional results between the two groups. Delayed union or nonunion and soft tissue incarceration were significantly reduced in the IM + TBT group compared to those in the TBT group. Conclusion Both TBT and IM + TBT achieved satisfactory postoperative bone and functional outcomes in patients with segmental tibial defects > 6 cm following posttraumatic osteomyelitis, while IM + TBT had a significantly lower incidence of postoperative complication in delayed union or nonunion and soft tissue incarceration, as well as faster docking union. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05501-8.
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Affiliation(s)
- Yimurang Hamiti
- Department of Microrepair and Reconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People's Republic of China
| | - Maimaiaili Yushan
- Department of Microrepair and Reconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People's Republic of China
| | - Ainizier Yalikun
- Department of Microrepair and Reconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People's Republic of China
| | - Cheng Lu
- Department of Microrepair and Reconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People's Republic of China
| | - Aihemaitijiang Yusufu
- Department of Microrepair and Reconstructive Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People's Republic of China.
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Sun H, Godbout C, Ryan G, Hoit G, Higgins J, Schemitsch EH, Nauth A. The induced membrane technique: Optimization of bone grafting in a rat model of segmental bone defect. Injury 2022; 53:1848-1853. [PMID: 35341595 DOI: 10.1016/j.injury.2022.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The induced membrane technique (IMT) is a two-stage surgical procedure used to treat fracture nonunion and bone defects. Although there is an increasing number of animal studies investigating the IMT, few have examined the outcomes of bone healing after a second stage grafting procedure. This study aimed at comparing two bone grafting procedures, as part of the IMT, in order to establish a rat model providing consistent healing outcomes. METHODS In male Fischer 344 rats, we created a 5 mm defect in the right femur, stabilized the bone with a plate and screws, and inserted a polymethylmethacrylate spacer into the defect. Four weeks later, the spacer was removed. Bone graft was harvested from a donor rat and placed into the defect, followed by membrane and wound closure. Experiments were conducted in two groups. In group 1 (n = 11), the bone graft contained a variable amount of cortical and cancellous bone, the time from donor euthanasia to grafting was up to 240 min, and one donor rat provided graft for 5-6 recipients. In group 2 (n = 12), we reduced the contribution of cortical bone to the graft, included bone marrow, and kept donor euthanasia to grafting time under 150 min. One donor was used per 3-4 recipients. The volume of graft per recipient and all other elements of the protocol were the same across groups. Bone healing at 12 weeks post grafting was compared radiographically by two orthopaedic surgeons in a blinded fashion, based on union status and a modified Lane & Sandhu score. RESULTS Healing rates improved from 36.4% in Group 1 to 91.6% in Group 2. There was a significant relationship between the methods and resulting union status (p = 0.004). The odds of achieving full union were significantly higher in group 2 compared to group 1 (odds ratio=19.25, 95% confidence interval [1.77-209.55]; p = 0.009). The average radiographic score was also significantly higher in group 2 (p = 0.005). CONCLUSION The revised bone grafting method significantly improved the healing outcomes and contributed to establishing a consistent rat model of the IMT. This model can benefit preclinical investigations by allowing for reliable and clinically-relevant comparisons.
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Affiliation(s)
- Hening Sun
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Charles Godbout
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada
| | - Gareth Ryan
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Graeme Hoit
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - James Higgins
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Aaron Nauth
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
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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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The induced membrane technique in animal models: a systematic review. OTA Int 2022; 5:e176. [PMID: 35282388 PMCID: PMC8900461 DOI: 10.1097/oi9.0000000000000176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/15/2021] [Indexed: 01/10/2023]
Abstract
Objectives: Data Sources: Study Selection: Data Extraction: Data Synthesis: Conclusions:
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Starks AO, Owen J, Isaacs J. Evaluation of the Induced Membrane for Neurotrophic Factors. J Hand Surg Am 2022; 47:130-136. [PMID: 34865951 DOI: 10.1016/j.jhsa.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/09/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Despite gaining popularity as a bridge for small and moderate nerve gaps, an acellular nerve allograft (ANA) lacks many of the neurotrophic characteristics of a nerve autograft. Pseudomembranes induced to form around temporary skeletal spacers are rich in growth factors. Induced membranes may have beneficial neurotrophic factors which could support ANA. METHODS Twenty-two male Sprague-Dawley rats underwent resection of 2 cm of the sciatic nerve. A silicone rod was inset in the defect of 11 experimental rats, and marking sutures only were placed in the nerve stumps of the remaining 11 control rats. After allowing 4 weeks for tissue maturation, tissue samples harvested from the induced membrane (experimental group) and the tissue bed (control group) were analyzed using Luminex multiplex assay to quantify differences in detectable levels of the following neurotrophic factors: nerve growth factor, glial-derived nerve factor, vascular endothelial growth factor, and transforming growth factor ß (TGF-ß) 1, 2, and 3, interleukin-1ß, and monocyte chemoattractant protein 1. RESULTS No difference was detected between the control and experimental groups in levels of vascular endothelial growth factor. Higher levels of TGF-ß1, TGF-ß2, TGF-ß3, glial-derived nerve factor, nerve growth factor, monocyte chemoattractant protein 1, and interleukin-1ß were detected in the experimental group. CONCLUSIONS In the setting of peripheral nerve injury, an induced membrane has higher levels of several neurotrophic factors that may support nerve regeneration compared to wound bed cicatrix. CLINICAL RELEVANCE This investigation provides impetus for further study examining the utility of using a staged induced membrane technique in conjunction with delayed nerve grafting in reconstruction of some peripheral nerve defects.
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Affiliation(s)
- Alexandria O Starks
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA.
| | - John Owen
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Jonathan Isaacs
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA
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Niikura T, Oda T, Jimbo N, Komatsu M, Oe K, Fukui T, Matsumoto T, Hayashi S, Matsushita T, Itoh T, Kuroda R. Immunohistochemical analysis revealed the expression of bone morphogenetic proteins-4, 6, 7, and 9 in human induced membrane samples treated with the Masquelet technique. J Orthop Surg Res 2022; 17:29. [PMID: 35033126 PMCID: PMC8760771 DOI: 10.1186/s13018-022-02922-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/06/2022] [Indexed: 01/11/2023] Open
Abstract
Background Induced membrane (IM) is the key component of Masquelet reconstruction surgery for the treatment of bone defects. IM is formed around the cement spacer and is known to secrete growth factors and osteoinductive factors. However, there is limited evidence available concerning the presence of osteoinductive factors in IM. This study aimed to investigate the existence of bone morphogenetic proteins (BMPs) in IM harvested from patients during the treatment of bone defects using the Masquelet technique. Methods This study involved six patients whose bone defects had been treated using the Masquelet technique. The affected sites were the femur (n = 3) and the tibia (n = 3). During the second-stage surgery, 1 cm2 pieces of IM were harvested. Histological sections of IM were immunostained with anti-BMP-4, 6, 7, and 9 antibodies. Human bone tissue served as the positive control. Results The presence of BMP-4, 6, 7, and 9 was observed in all IM samples. Further, immunolocalization of BMP-4, 6, 7, and 9 was observed in blood vessels and fibroblasts in all IM samples. Immunolocalization of BMP-4, 6, 7, and 9 was also observed in bone tissue within the IM in one sample, in which osteogenesis inside the IM was observed. Conclusions This study showed that osteoinductive factors BMP-4, 6, 7, and 9 were present in the IM harvested from patients, providing evidence indicating that the Masquelet technique effectively contributes to healing large bone defects. Therefore, it may be possible for surgeons to omit the addition of BMPs to bone grafts, given the endogenous secretion of BMPs from the IM.
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Affiliation(s)
- Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takahiro Oda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Naoe Jimbo
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masato Komatsu
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Gessmann J, Rosteius T, Baecker H, Sivalingam K, Peter E, Schildhauer TA, Köller M. Is the bioactivity of induced membranes time dependent? Eur J Trauma Emerg Surg 2021; 48:3051-3061. [PMID: 34873632 PMCID: PMC9360131 DOI: 10.1007/s00068-021-01844-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/21/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE The induced membrane technique (IMT) is a two-stage surgical procedure for reconstruction of bone defects. Bone grafting (second stage of IMT) is recommend after 4-8 weeks assuming the highest bioactivity of IMs. However, larger studies concerning the biology and maturation of IMs and a potential time dependency of the bioactivity are missing. Therefore, aim of this study was the time-dependent structural and cellular characterization of cement spacer IMs concomitantly to an analysis of membrane bioactivity. METHODS IMs from 60 patients (35-82 years) were obtained at different maturation stages (1-16 weeks). IMs were studied by histology and co-culture with mesenchymal stem cells (MSC). IM lysates were analyzed by ELISA and protein microarray. RESULTS Increasing vascularization and fibrosis were found in membranes older than 4 and 7 weeks, respectively. MSC grew out from all membranes and all membranes enhanced proliferation of cultured MSC. Osteocalcin and osteopontin (in membrane lysates or induced in MSC by membrane tissue) were found over all time points without significant differences. In contrast to alkaline phosphatase activity, increasing levels of osteoprotegerin were found in membranes. CONCLUSION The histological structure of IMs changes during growth and maturation, however, biologically active MSC and factors related to osteogenesis are found over all time points with minor changes. Thus, membranes older than 8 weeks exert regenerative capacities comparable to the younger ones. The postulated narrow time frame of 4-8 weeks until bone grafting can be questioned and surgeons may choose timing for the second operation more independently and based on other clinical factors.
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Affiliation(s)
- Jan Gessmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas Rosteius
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Hinnerk Baecker
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Kavitha Sivalingam
- Department of Surgical Research, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Elvira Peter
- Department of Surgical Research, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Manfred Köller
- Department of Surgical Research, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
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Du J, Yin Z, Cheng P, Han P, Shen H. Novel piston technique versus Ilizarov technique for the repair of bone defect after lower limb infection. J Orthop Surg Res 2021; 16:704. [PMID: 34863237 PMCID: PMC8642891 DOI: 10.1186/s13018-021-02844-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to compare the effectiveness and complications of a novel piston technique versus the Ilizarov technique for the repair of bone defects after lower limb infection. PATIENTS AND METHODS We retrospectively reviewed 41 patients who had been treated at our department for lower extremity bone defects following osteomyelitis. There were 38 men and three women with a mean age of 43.41 (range, 12-69 years). The infected bone defects involved 36 tibias and five femurs. The piston technique (PT, group A) was used in 12 patients and the Ilizarov technique (IT, group B) in 29 patients. The mean follow-up period was 28.50 months (PT) and 29.90 months (IT). The modified Application of Methods of Illizarov (ASAMI) criteria was used to evaluate bone healing and functional recovery. RESULTS Complete eradication of the infection and union of docking sites were accomplished in both groups. The mean external fixator index (EFI) was 42.32 days/cm in group A versus 58.85 days/cm in group B (p < 0.001). The bone outcomes were similar between groups A and B (p = 0.558) (excellent [9 vs. 19], good [3 vs.10]); group A showed better functional outcomes than group B (p < 0.05) (excellent [7 vs. 6], good [4 vs. 12], fair [0 vs. 10] and poor [1 vs. 1]). Pain was the most common complaint during follow-up, and group A had fewer cases of pin tract infection (1 vs. 6), adjacent joint stiffness (3 vs. 8), and delayed healing of the joint (0 vs. 3). CONCLUSIONS Satisfactory bone healing can be achieved by using both PT and IT, although PT demonstrated better functional results, lower EFI, and allowed early removal of the external fixation. We found that this novel piston technique can improve the comfort of patients, reduce the incidence of complications, and provide rapid and convenient rehabilitation.
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Affiliation(s)
- Jiafei Du
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zifei Yin
- Joint Department, Kunshan Hospital of Traditional Chinese Medicine affiliated to Nanjing University of Traditional Chinese Medicine, Jiangsu, China
| | - Pengfei Cheng
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Pei Han
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Hao Shen
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China. .,Orthopaedic Department, Jinjiang Municipal Hospital, Fujian, China.
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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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Coris JGF, Rahal SC, Fonseca-Alves CE, Mamprim MJ, Inamassu LR, Sampaio ABDA, Kano WT, Mesquita LDR, Silva Junior JIDS. Effect of low-level laser therapy on the membrane induced by the Masquelet technique at an orthotopic site in rabbits. Acta Cir Bras 2021; 36:e361003. [PMID: 34817024 PMCID: PMC8610207 DOI: 10.1590/acb361003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/20/2021] [Indexed: 01/22/2023] Open
Abstract
Purpose: To evaluate the low-level laser therapy (LLLT) on the membrane induced by the Masquelet technique in rabbits. Methods: Twelve Norfolk rabbits at approximately 3 months of age were used. A 1-cm segmental defect was induced in both radii, which were filled with polymethylmethacrylate cylinder. LLLT was used postoperatively in the bone defect of one of the forelimbs every 48 hours for 15 days. Six rabbits were euthanatized on third and sixth postoperative weeks. Results: In both forelimbs, radiographs showed new bone growth from radius cut ends on the third postoperative week and more advanced stage on the sixth postoperative week. Ultrasound showed induced membrane one week after the surgery. Histologically, there were no significant differences in the semi-quantitative score of inflammation intensity, total number of blood vessels, bone metaplasia, and collagen. The average thicknesses were 2,050.17 and 1,451.96 μm for control membranes and 2,724.26 and 2,081.03 μm for irradiated membranes, respectively, on third and sixth postoperative weeks. Vascular endothelial growth factor A (VEGF-A) and platelet derived growth factor (PDGF) expression were present in the induced membranes of control and irradiated forelimbs, but there was no significant difference. Conclusions: Based on assessment methods, it was not possible to demonstrate the effect of LLLT on the induced membrane.
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Xiao H, Wang S, Wang F, Dong S, Shen J, Xie Z. Locking Compression Plate as an External Fixator for the Treatment of Tibia Infected Bone Defects. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021. [PMID: 34496424 DOI: 10.1055/a-1545-5363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE This study was designed to observe the medium-term efficacy of an induced membrane technique combined with a locking compression plate as an external fixator for the treatment of tibia infected bone defects. METHODS Patients with a tibial infection were admitted to our department between January 2013 and November 2014. All patients were treated with the induced membrane technique. In the first stage, polymethyl methacrylate (PMMA) cement was implanted in the defects after debridement and then fixed with a locking compression plate (LCP) as an external fixator. In the second stage, bone grafts were implanted to rebuild the defects. The external plates were replaced with nails in 57 patients (internal group), and the remaining 30 patients were not exchanged with fixation (external group). The infection control rate, bone union rate, and complications of the two groups were compared. RESULTS Eighty-seven patients were enrolled in this study, and all patients had a minimum follow-up of 5 years (average 62.8 months) after grafting. Eighty-three patients (95.4%) achieved bone union, and the average union time was 6.77 months. Five patients (5.7%) experienced recurrence of infection. Complications included pin tract infection, fixation loosening, deformity connection, and limitation of joint range of motion (ROM). No significant differences in the infection control rate or bone defect union rate were noted between the two groups. The overall rate of complications in the external group was 50%, which was greater than that noted in the internal group (21.1%). CONCLUSIONS Locking compression plates are external fixators with smaller sizes that are easier to operate than conventional annular fixators or assembled external fixators. The use of locking compression plates in combination with the induced membrane technique in the treatment of tibia infected bone defects can achieve good clinical efficacy after medium-term follow-up.
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Affiliation(s)
- Hong Xiao
- Department of Orthopaedics, No. 958 Hospital of Army, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shulin Wang
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Feibo Wang
- Department of Orthopaedics, No. 958 Hospital of Army, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Sun Dong
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Shen
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhao Xie
- Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Chu C, Zhao X, Rung S, Xiao W, Liu L, Qu Y, Man Y. Application of biomaterials in periodontal tissue repair and reconstruction in the presence of inflammation under periodontitis through the foreign body response: Recent progress and perspectives. J Biomed Mater Res B Appl Biomater 2021; 110:7-17. [PMID: 34142745 DOI: 10.1002/jbm.b.34891] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 02/06/2023]
Abstract
Periodontitis would cause dental tissue damage locally. Biomaterials substantially affect the surrounding immune microenvironment through treatment-oriented local inflammatory remodeling in dental periodontitis. This remodeling process is conducive to wound healing and periodontal tissue regeneration. Recent progress in understanding the foreign body response (FBR) and immune regulation, including cell heterogeneity, and cell-cell and cell-material interactions, has provided new insights into the design criteria for biomaterials applied in treatment of periodontitis. This review discusses recent progress and perspectives in the immune regulation effects of biomaterials to augment or reconstruct soft and hard tissue in an inflammatory microenvironment of periodontitis.
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Affiliation(s)
- Chenyu Chu
- Department of Oral Implantology & National Clinical Research Center for Oral Diseases & State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xiwen Zhao
- Department of Oral Implantology & National Clinical Research Center for Oral Diseases & State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Shengan Rung
- Department of Oral Implantology & National Clinical Research Center for Oral Diseases & State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Wenlan Xiao
- Department of Oral Implantology & National Clinical Research Center for Oral Diseases & State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Li Liu
- State Key Laboratory of Biotherapy and Laboratory, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Sichuan University, Chengdu, China
| | - Yili Qu
- Department of Oral Implantology & National Clinical Research Center for Oral Diseases & State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yi Man
- Department of Oral Implantology & National Clinical Research Center for Oral Diseases & State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Littlefield CP, Wang C, Leucht P, Egol KA. The Basic Science Behind the Clinical Success of the Induced Membrane Technique for Critical-Sized Bone Defects. JBJS Rev 2021; 9:01874474-202106000-00010. [PMID: 34125719 DOI: 10.2106/jbjs.rvw.20.00206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The induced membrane technique (IMT) takes advantage of an osteoinductive environment that is created by the placement of a cement spacer into a bone defect. » Most commonly, a polymethylmethacrylate (PMMA) spacer has been used, but spacers made from other materials have emerged and achieved good clinical outcomes. » The IMT has demonstrated good results for long-bone repair; however, more research is required in order to optimize union rates as well as delineate more precise indications and surgical timing.
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Niikura T, Jimbo N, Komatsu M, Oe K, Fukui T, Matsumoto T, Hayashi S, Matsushita T, Sakai Y, Itoh T, Kuroda R. Histological analysis of induced membranes in patients whose bone defects were treated with the Masquelet technique to identify factors affecting the vascularity of induced membranes. J Orthop Surg Res 2021; 16:248. [PMID: 33849590 PMCID: PMC8042897 DOI: 10.1186/s13018-021-02404-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background Rich vascularity of the induced membrane (IM) is important for Masquelet reconstruction surgery. The factors affecting IM vascularity are not completely understood. This study aimed to investigate these factors using histological samples of human IMs. Methods We retrospectively evaluated 36 patients whose bone defects were treated using the Masquelet technique. Two clinical pathologists analyzed histological sections of IM pieces (1 cm2). The number of blood vessels per 1 mm2 was counted and compared among men and women, femur or tibia, with and without free flap surgery, antibiotic impregnation to the cement, osteogenesis inside the membrane, smoking, and diabetes mellitus. The number of blood vessels within the same patient was compared among different time points. Correlation analysis was performed among blood vessel numbers and patient age, duration of cement spacer placement, and histological grading scales (inflammation, foreign body reaction, and fibrosis). Results IM formation with rich vascularity and some inflammation, foreign body reaction, and fibrosis were histologically confirmed in all patients. We found 37.4 ± 19.1 blood vessels per 1 mm2. The number of blood vessels was significantly lower in patients with than in those without free flap surgery; it was higher in patients with osteogenesis inside the IM. No significant correlations were found in any of the analyses. Conclusion Sex, patient age, smoking, diabetes mellitus, femur or tibia, duration of cement spacer placement, and antibiotic impregnation to the cement did not affect IM vascularization. IM vascularization was reduced in patients with than in those without free flap surgery.
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Affiliation(s)
- Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Naoe Jimbo
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Masato Komatsu
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yoshitada Sakai
- Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Alford AI, Nicolaou D, Hake M, McBride-Gagyi S. Masquelet's induced membrane technique: Review of current concepts and future directions. J Orthop Res 2021; 39:707-718. [PMID: 33382115 PMCID: PMC8005442 DOI: 10.1002/jor.24978] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/16/2020] [Accepted: 12/28/2020] [Indexed: 02/04/2023]
Abstract
Masquelet's induced membrane technique (MIMT) is a relatively new, two-stage surgical procedure to reconstruct segmental bone defects. First performed by Dr. Masquelet in the mid-1980s, MIMT has shown great promise to revolutionize critical-sized bone defect repair and has several advantages over its alternative, distraction osteogenesis (DO). Also, its success in extremely challenging cases (defects > 15 cm) suggests that its study could lead to discovery of novel biological mechanisms that might be at play during segmental defect healing and fracture non-union. MIMT's advantages over DO have led to a world-wide increase in MIMT procedures over the past decades. However, MIMT often needs to be repeated and so the average initial success rate in adults lags significantly behind that of DO (86% vs 95%, respectively). The autologous foreign-body membrane created during the first stage by the immune system's response to a polymethyl methacrylate bone cement spacer is critical to supporting the morselized bone graft implanted in the second stage. However, the biological and/or physical mechanisms by which the membrane supports graft to bone union are unclear. This lack of knowledge makes refining MIMT and improving the success rates through technique improvements and patient selection a significant challenge and hinders wider adoption. In this review, current knowledge from basic, translational, and clinical studies is summarized. The dynamics of both stages under normal conditions as well as with drug or material perturbations is discussed along with perspectives on high-priority future research directions.
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Affiliation(s)
- Andrea I. Alford
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO
| | - Mark Hake
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
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Hoit G, Kain MS, Sparkman JW, Norris BL, Conway JD, Watson JT, Tornetta P, Nauth A. The induced membrane technique for bone defects: Basic science, clinical evidence, and technical tips. OTA Int 2021; 4:e106(1-5). [PMID: 37608856 PMCID: PMC10441675 DOI: 10.1097/oi9.0000000000000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/09/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
The clinical management of large bone defects continues to be a difficult clinical problem to manage for treating surgeons. The induced membrane technique is a commonly employed strategy to manage these complex injuries and achieve bone union. Basic science and clinical evidence continue to expand to address questions related to the biology of the membrane and how interventions may impact clinical outcomes. In this review, we discuss the basic science and clinical evidence for the induced membrane technique as well as provide indications for the procedure and technical tips for performing the induced membrane technique.
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Affiliation(s)
- Graeme Hoit
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael S Kain
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Jeremy W Sparkman
- Department of Orthopaedic Surgery, Oklahoma State University, Tulsa, OK
| | - Brent L Norris
- Department of Orthopaedic Surgery, Oklahoma State University, Tulsa, OK
| | - Janet D Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Aaron Nauth
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
- Department of Orthopaedic Surgery, St. Michael's Hospital. Toronto ON, Canada
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27
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Shen J, Sun D, Yu S, Fu J, Wang X, Wang S, Xie Z. Radiological and clinical outcomes using induced membrane technique combined with bone marrow concentrate in the treatment of chronic osteomyelitis of immature patients. Bone Joint Res 2021; 10:31-40. [PMID: 33380210 PMCID: PMC7845462 DOI: 10.1302/2046-3758.101.bjr-2020-0229.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims Treatment of chronic osteomyelitis (COM) for young patients remains a challenge. Large bone deficiencies secondary to COM can be treated using induced membrane technique (IMT). However, it is unclear which type of bone graft is optimal. The goal of the study was to determine the clinical effectiveness of bone marrow concentrator modified allograft (BMCA) versus bone marrow aspirate mixed allograft (BMAA) for children with COM of long bones. Methods Between January 2013 and December 2017, 26 young patients with COM were enrolled. Different bone grafts were applied to repair bone defects secondary to IMT procedure for infection eradication. Group BMCA was administered BMCA while Group BMAA was given BMAA. The results of this case-control study were retrospectively analyzed. Results Patient infection in both groups was eradicated after IMT surgery. As for reconstruction surgery, no substantial changes in the operative period (p = 0.852), intraoperative blood loss (p = 0.573), or length of hospital stay (p = 0.362) were found between the two groups. All patients were monitored for 12 to 60 months. The median time to bone healing was 4.0 months (interquartile range (IQR) 3.0 to 5.0; range 3 to 7) and 5.0 months (IQR 4.0 to 7.0; range 3 to 10) in Groups BMCA and BMAA, respectively. The time to heal in Group BMCA versus Group BMAA was substantially lower (p = 0.024). Conclusion IMT with BMCA or BMAA may attain healing in large bone defects secondary to COM in children. The bone healing time was significantly shorter for BMCA, indicating that this could be considered as a new strategy for bone defect after COM treatment. Cite this article: Bone Joint Res 2021;10(1):31–40.
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Affiliation(s)
- Jie Shen
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dong Sun
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shengpeng Yu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China.,Department of Orthopaedics, Dujiangyan Medical Center, Dujiangyan, Sichuan, China
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing, China
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Comparison between Tonifying Kidney Yang and Yin in Treating Segmental Bone Defects Based on the Induced Membrane Technique: An Experimental Study in a Rat Model. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:6575127. [PMID: 33424987 PMCID: PMC7781691 DOI: 10.1155/2020/6575127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/24/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023]
Abstract
Tonifying kidney therapy consisting of tonifying kidney yang and yin is the basic principle of Chinese medicine in treating segmental bone defects (SBDs). Previous studies have demonstrated the presence of the differences between tonifying kidney yang and yin in bone metabolism of osteoporosis and distraction osteogenesis models. However, whether the difference between the two tonifying kidney methods in bone repair for the induced membrane (IM) technique occurs or what is the difference remain unclear. Angiogeneic-osteogenic coupling plays an important role in bone repair and the induced membrane couples angiogenesis with the later osteogenesis during the IM process. This study aimed at investigating the effects of tonifying kidney yang (total flavonoids of Rhizoma Drynariae, TFRD) and yin (plastrum testudinis extract, PTE) on angiogenesis and osteogenesis in the IM-treated SBDs. Rats of 6 mm tibia bone defect model treated with IM were divided into five groups: the control group, the model group, the tonifying kidney yang group (TFRD-treated group), the tonifying kidney yin group (PTE-treated group), and the western medicine group. At 4 weeks after insertion of the polymethylmethacrylate (PMMA), three caudal vertebrae from the tail in each rat were implanted into the 6 mm defect gap. Radiographical, histological, immunohistochemical, and immunofluorescent analyses were performed to assess bone and vessel formation at 4 or 12 weeks after insertion of the PMMA, respectively. Our results revealed that TFRD and PTE were beneficial to both angiogenesis and osteogenesis. TFRD exerted a better effect on angiogenesis than PTE and achieved a better result in stage 1 rather than in stage 2 of IM, whereas PTE was superior to TFRD in osteogenesis and achieved a better result in stage 2 instead of stage 1. Collectively, these findings elucidated the beneficial effects of tonifying kidney yang and yin on angiogenesis and osteogenesis of SBD repair during the IM process, as well as the difference that tonifying kidney yang surpasses tonifying kidney yin in angiogenesis while tonifying kidney yin outperforms tonifying kidney yang in osteogenesis, which suggests that the combination between the application of tonifying kidney yang method in stage 1 of IM and tonifying kidney yin method in stage 2 may achieve better repair efficiency.
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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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30
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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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Gaillard J, Masquelet AC, Boutroux P, Cambon-Binder A. Induced-membrane treatment of refractory humeral non-union with or without bone defect. Orthop Traumatol Surg Res 2020; 106:803-811. [PMID: 32446812 DOI: 10.1016/j.otsr.2020.02.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 12/16/2019] [Accepted: 02/06/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Treatment of humeral non-union with or without bone defect is complex, with non-negligible rates of complication and failure. Few reports focused on management of treatment failure. OBJECTIVE The study hypothesis was that the induced-membrane technique associated in a 2-stage strategy to internal fixation provides systematic bone healing in refractory humeral non-union. MATERIAL AND METHODS The study included 15 patients, with a median age of 46.6 years, with humeral non-union of a mean 24 months' progression and mean history of 3 attempted revision surgeries. Seven patients showed bone defect, exceeding 5cm in 2 cases. Six had history of radial palsy. RESULTS Consolidation was achieved in all cases, at a mean 4.6 months. Ten patients underwent radial nerve transposition, 6 of whom had shown radial motor nerve palsy; all recovered within 2 to 5 months. There was 1 case of superficial infection, and 1 of seroma. DISCUSSION The induced-membrane technique ensures bone healing due to the biological properties of the membrane; the main drawback is the need for 2-stage surgery. When bone defect exceeds 5cm, a multi-perforated fibula segment can be placed inside the membrane to increase primary stability and enhance bone integration. CONCLUSION The induced-membrane technique is suited to humeral non-union, with or without bone defect. The 2-stage strategy is mandatory in case of suspected latent infection. In the 2-stage procedure, anteromedial radial nerve transposition facilitates the bone-graft stage. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Julien Gaillard
- Service de Chirurgie Orthopédique et Traumatologique-SOS Main, Chirurgie Réparatrice de l'Appareil Locomoteur, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Orthopedic surgery department, American Hospital of Paris, 63, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France.
| | - Alain-Charles Masquelet
- Service de Chirurgie Orthopédique et Traumatologique-SOS Main, Chirurgie Réparatrice de l'Appareil Locomoteur, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Pierre Boutroux
- Service de Chirurgie Orthopédique et Traumatologique-SOS Main, Chirurgie Réparatrice de l'Appareil Locomoteur, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Adeline Cambon-Binder
- Service de Chirurgie Orthopédique et Traumatologique-SOS Main, Chirurgie Réparatrice de l'Appareil Locomoteur, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
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Klein C, Monet M, Barbier V, Vanlaeys A, Masquelet AC, Gouron R, Mentaverri R. The Masquelet technique: Current concepts, animal models, and perspectives. J Tissue Eng Regen Med 2020; 14:1349-1359. [PMID: 32621637 DOI: 10.1002/term.3097] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022]
Abstract
Bone reconstruction within a critical-sized defect remains a real challenge in orthopedic surgery. The Masquelet technique is an innovative, two-step therapeutic approach for bone reconstruction in which the placement of a poly (methylmethacrylate) spacer into the bone defect induces the neo-formation of a tissue called "induced membrane." This surgical technique has many advantages and is often preferred to a vascularized bone flap or Ilizarov's technique. Although the Masquelet technique has achieved high clinical success rates since its development by Alain-Charles Masquelet in the early 2000s, very little is known about how the process works, and few animal models of membrane induction have been developed. Our successful use of this technique in the clinic and our interest in the mechanisms of tissue regeneration (notably bone regeneration) prompted us to develop a surgical model of the Masquelet technique in rats. Here, we provide a comprehensive review of the literature on animal models of membrane induction, encompassing the defect site, the surgical procedure, and the histologic and osteogenic properties of the induced membrane. We also discuss the advantages and disadvantages of those models to facilitate efforts in characterizing the complex biological mechanisms that underlie membrane induction.
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Affiliation(s)
- Céline Klein
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Michael Monet
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Vincent Barbier
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Alison Vanlaeys
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Alain-Charles Masquelet
- Service de Chirurgie Orthopédique, Traumatologie et Chirurgie de la Main, Saint-Antoine Hospital, Paris, France
| | - Richard Gouron
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Romuald Mentaverri
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France.,Department of Biochemistry and Endocrine Biology, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France
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Borzunov DY, Kolchin SN, Malkova TA. Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: Problems solved and unsolved. World J Orthop 2020; 11:304-318. [PMID: 32572367 PMCID: PMC7298454 DOI: 10.5312/wjo.v11.i6.304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ilizarov non-free bone plasty is a method of distraction osteogenesis using the Ilizarov apparatus for external fixation which originated in Russia and was disseminated across the world. It has been used in long bone defect and nonunion management along with free vascularized grafting and induced membrane technique. However, the shortcomings and problems of these methods still remain the issues which restrict their overall use. AIM To study the recent available literature on the role of Ilizarov non-free bone plasty in long bone defect and nonunion management, its problems and the solutions to these problems in order to achieve better treatment outcomes. METHODS Three databases (PubMed, Scopus, and Web of Science) were searched for literature sources on distraction osteogenesis, free vascularized grafting and induced membrane technique used in long bone defect and nonunion treatment within a five-year period (2015-2019). Full-text clinical articles in the English language were selected for analysis only if they contained treatment results, complications and described large patient samples (not less than ten cases for congenital, post-tumor resection cases or rare conditions, and more than 20 cases for the rest). Case reports were excluded. RESULTS Fifty full-text articles and reviews on distraction osteogenesis were chosen. Thirty-five clinical studies containing large series of patients treated with this method and problems with its outcome were analyzed. It was found that distraction osteogenesis techniques provide treatment for segmental bone defects and nonunion of the lower extremity in many clinical situations, especially in complex problems. The Ilizarov techniques treat the triad of problems simultaneously (bone loss, soft-tissue loss and infection). Management of tibial defects mostly utilizes the Ilizarov circular fixator. Monolateral fixators are preferable in the femur. The use of a ring fixator is recommended in patients with an infected tibial bone gap of more than 6 cm. High rates of successful treatment were reported by the authors that ranged from 77% to 100% and depended on the pathology and the type of Ilizarov technique used. Hybrid fixation and autogenous grafting are the most applicable solutions to avoid after-frame regenerate fracture or deformity and docking site nonunion. CONCLUSION The role of Ilizarov non-free bone plasty has not lost its significance in the treatment of segmental bone defects despite the shortcomings and treatment problems encountered.
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Affiliation(s)
- Dmitry Y Borzunov
- Department of Traumatology and Orthopedics, Ural State Medical University, Ekaterinburg 620109, Russia
| | - Sergei N Kolchin
- Orthopaedic Department 4, Ilizarov National Medical Research Centre for Traumatology and Orthopaedics, Kurgan 640014, Russia
| | - Tatiana A Malkova
- Department for Medical Information and Analysis, Ilizarov National Medical Research Centre for Traumatology and Orthopaedics, Kurgan 640014, Russia
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Advances in the Masquelet technique: Myeloid-derived suppressor cells promote angiogenesis in PMMA-induced membranes. Acta Biomater 2020; 108:223-236. [PMID: 32165192 DOI: 10.1016/j.actbio.2020.03.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/02/2023]
Abstract
The periosteum plays a critical role in bone formation and defect reconstruction. The concept of tissue engineering in the periosteum has been suggested to solve the clinical problems related to bone defect repair. Insertion of polymethyl methacrylate (PMMA) bone cement can induce the autologous generation of a tissue-engineered periosteum and has been considered as a promising strategy for bone defect reconstruction. The PMMA-induced membrane is a crucial element in the reconstruction of bone defects, especially for angiogenesis, but its biological mechanism remains elusive. Here, a PMMA-induced membrane model was established using a femoral critically sized defect in mice. We identified myeloid-derived suppressor cells (MDSCs) as a regulatory component of induced membrane vascularization. The increased number of MDSCs was markedly linked to increased membrane thickness and capillary density. Importantly, the results of an in vitro coculture assay indicated that MDSCs of the induced membrane further facilitated the angiogenic capacity of human umbilical vein endothelial cells (HUVECs) by upregulating the expression of VEGFA, Ang2 and HIF-1α. Furthermore, signaling pathway blockade results suggested that STAT3 activation is involved in the upregulation of VEGFA, Ang2 and HIF-1α expression in induced membrane MDSCs. Our findings provide new insights into the mechanism of angiogenesis in the PMMA-induced membrane and confirm the key signaling molecules of MDSCs in induced membrane angiogenesis. Based on these results, this strategy may become a new therapy for the treatment of large bone defects in the future. STATEMENT OF SIGNIFICANCE: In this study, we established an autologous tissue-engineered periosteum - PMMA-induced membrane, which was formed by the foreign body reaction to PMMA bone cement. The induced membrane establishes a blood supply for the large bone defect healing. After investigation, our study discovered the critical cell type in the formation and angiogenesis processes of the induced membrane, myeloid-derived suppressor cells (MDSCs). We revealed that MDSCs of the induced membrane promote the angiogenesis of endothelial cells through the expression of VEGFA, Ang2 and HIF-1α, which was upregulated by the activation of STAT3 signaling. Our findings clarified the beneficial effect of MDSCs in the angiogenesis of bone repair, and offered an additional target for the study of foreign body reactions to bone repair materials.
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Durand M, Barbier L, Mathieu L, Poyot T, Demoures T, Souraud JB, Masquelet AC, Collombet JM. Towards Understanding Therapeutic Failures in Masquelet Surgery: First Evidence that Defective Induced Membrane Properties are Associated with Clinical Failures. J Clin Med 2020; 9:jcm9020450. [PMID: 32041238 PMCID: PMC7073843 DOI: 10.3390/jcm9020450] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/29/2020] [Indexed: 12/13/2022] Open
Abstract
The two-stage Masquelet induced-membrane technique (IMT) consists of cement spacer-driven membrane induction followed by an autologous cancellous bone implantation in this membrane to promote large bone defect repairs. For the first time, this study aims at correlating IMT failures with physiological alterations of the induced membrane (IM) in patients. For this purpose, we compared various histological, immunohistochemical and gene expression parameters obtained from IM collected in patients categorized lately as successfully (Responders; n = 8) or unsuccessfully (Non-responders; n = 3) treated with the Masquelet technique (6 month clinical and radiologic post-surgery follow-up). While angiogenesis or macrophage distribution pattern remained unmodified in non-responder IM as compared to responder IM, we evidenced an absence of mesenchymal stem cells and reduced density of fibroblast-like cells in non-responder IM. Furthermore, non-responder IM exhibited altered extracellular matrix (ECM) remodeling parameters such as a lower expression ratio of metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinases (TIMP-1) mRNA as well as an important collagen overexpression as shown by picrosirius red staining. In summary, this study is the first to report evidence that IMT failure can be related to defective IM properties while underlining the importance of ECM remodeling parameters, particularly the MMP-9/TIMP-1 gene expression ratio, as early predictive biomarkers of the IMT outcome regardless of the type of bone, fracture or patient characteristics.
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Affiliation(s)
- Marjorie Durand
- French Military Biomedical Research Institute (IRBA), BP73, 91220 Brétigny-sur-Orge, France; (L.B.); (T.P.); (J.-M.C.)
- Correspondence: ; Tel.: +33-178-651-146
| | - Laure Barbier
- French Military Biomedical Research Institute (IRBA), BP73, 91220 Brétigny-sur-Orge, France; (L.B.); (T.P.); (J.-M.C.)
| | - Laurent Mathieu
- Percy Military Hospital, 101 avenue Henri Barbusse 92140 Clamart, France;
- Department of Surgery, French Medical Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran 75005 Paris, France
| | - Thomas Poyot
- French Military Biomedical Research Institute (IRBA), BP73, 91220 Brétigny-sur-Orge, France; (L.B.); (T.P.); (J.-M.C.)
| | - Thomas Demoures
- Bégin Military Hospital, 69 avenue de Paris, 94160 Saint-Mandé, France; (T.D.); (J.-B.S.)
| | - Jean-Baptiste Souraud
- Bégin Military Hospital, 69 avenue de Paris, 94160 Saint-Mandé, France; (T.D.); (J.-B.S.)
| | | | - Jean-Marc Collombet
- French Military Biomedical Research Institute (IRBA), BP73, 91220 Brétigny-sur-Orge, France; (L.B.); (T.P.); (J.-M.C.)
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Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis PV. Bone Repair Using the Masquelet Technique. J Bone Joint Surg Am 2019; 101:1024-1036. [PMID: 31169581 DOI: 10.2106/jbjs.18.00842] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alain Masquelet
- Department of Orthopaedic Surgery, Avicenne Hospital, Bobiny, France
| | - Nikolaos K Kanakaris
- Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Laurent Obert
- Traumatology, Reconstructive, and Plastic Surgery Unit, CHU Jean Minjoz, Besançon, France
| | - Paul Stafford
- Orthopedic Trauma Surgery of Oklahoma, Tulsa, Oklahoma
| | - Peter V Giannoudis
- Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.,Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
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Björkenheim R, Strömberg G, Ainola M, Uppstu P, Aalto-Setälä L, Hupa L, Pajarinen J, Lindfors NC. Bone morphogenic protein expression and bone formation are induced by bioactive glass S53P4 scaffolds in vivo. J Biomed Mater Res B Appl Biomater 2018; 107:847-857. [DOI: 10.1002/jbm.b.34181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/16/2018] [Accepted: 05/28/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Robert Björkenheim
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Gustav Strömberg
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Department of Surgery; Päijät-Häme Central Hospital; Lahti Finland
| | - Mari Ainola
- Department of Medicine, Clinicum; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Peter Uppstu
- Laboratory of Polymer Technology, Centre of Excellence in Functional Materials at Biological Interfaces; Åbo Akademi University; Turku Finland
| | - Laura Aalto-Setälä
- Johan Gadolin Process Chemistry Centre; Åbo Akademi University; Turku Finland
| | - Leena Hupa
- Johan Gadolin Process Chemistry Centre; Åbo Akademi University; Turku Finland
| | - Jukka Pajarinen
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Nina C. Lindfors
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Gaio N, Martino A, Toth Z, Watson JT, Nicolaou D, McBride-Gagyi S. Masquelet technique: The effect of altering implant material and topography on membrane matrix composition, mechanical and barrier properties in a rat defect model. J Biomech 2018; 72:53-62. [PMID: 29510858 PMCID: PMC5895482 DOI: 10.1016/j.jbiomech.2018.02.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/26/2022]
Abstract
The Masquelet technique is a surgical procedure to regenerate segmental bone defects. The two-phase treatment relies on the production of a vascularized foreign-body membrane to support bone grafts over three times larger than the traditional maximum. Historically, the procedure has always utilized a bone cement spacer to evoke membrane production. However, membrane formation can easily be effected by implant surface properties such as material and topology. This study sought to determine if the membrane's mechanical or barrier properties are affected by changing the spacer material to titanium or roughening the surface finish. Ten-week-old, male Sprague Dawley rats were given an externally stabilized, 6 mm femur defect which was filled with a pre-made spacer of bone cement (PMMA) or titanium (TI) with a smooth (∼1 μm) or roughened (∼8 μm) finish. After 4 weeks of implantation, the membranes were harvested, and the matrix composition, tensile mechanics, shrinkage, and barrier function was assessed. Roughening the spacers resulted in significantly more compliant membranes. TI spacers created membranes that inhibited solute transport more. There were no differences between groups in collagen or elastin distribution. This suggests that different membrane characteristics can be created by altering the spacer surface properties. Surgeons may unknowingly effecting membrane formation via bone cement preparation techniques.
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Affiliation(s)
- Natalie Gaio
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Alice Martino
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA.
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McBride-Gagyi S, Toth Z, Kim D, Ip V, Evans E, Watson JT, Nicolaou D. Altering spacer material affects bone regeneration in the Masquelet technique in a rat femoral defect. J Orthop Res 2018; 36:10.1002/jor.23866. [PMID: 29424019 PMCID: PMC6785358 DOI: 10.1002/jor.23866] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/30/2018] [Indexed: 02/04/2023]
Abstract
The Masquelet technique depends on pre-development of a foreign-body membrane to support bone regeneration with grafts over three times larger than the traditional maximum. To date, the procedure has always used spacers made of bone cement, which is the polymer polymethyl methacrylate (PMMA), to induce the foreign-body membrane. This study sought to compare (i) morphology, factor expression, and cellularity in membranes formed by PMMA, titanium, and polyvinyl alcohol sponge (PVA) spacers in the Masquelet milieu and (ii) subsequent bone regeneration in the same groups. Ten-week-old, male Sprague-Dawley rats were given an externally stabilized, 6 mm femur defect, and a pre-made spacer of PMMA, titanium, or PVA was implanted. All animals were given 4 weeks to form a membrane, and those receiving an isograft were given 10 weeks post-implantation to union. All samples were scanned with microCT to measure phase 1 and phase 2 bone formation. Membrane samples were processed for histology to measure membrane morphology, cellularity, and expression of the factors BMP2, TGFβ, VEGF, and IL6. PMMA and titanium spacers created almost identical membranes and phase 1 bone. PVA spacers were uniformly infiltrated with tissue and cells and did not form a distinct membrane. There were no quantitative differences in phase 2 bone formation. However, PMMA induced membranes supported functional union in 6 of 7 samples while a majority of titanium and PVA groups failed to achieve the same. Spacer material can alter the membrane enough to disrupt phase 2 bone formation. The membrane's role in bone regeneration is likely more than just as a physical barrier. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Daniel Kim
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Victoria Ip
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Emily Evans
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
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Scientific Understanding of the Induced Membrane Technique: Current Status and Future Directions. J Orthop Trauma 2017; 31 Suppl 5:S3-S8. [PMID: 28938383 DOI: 10.1097/bot.0000000000000981] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Luo F, Wang X, Wang S, Fu J, Xie Z. Induced membrane technique combined with two-stage internal fixation for the treatment of tibial osteomyelitis defects. Injury 2017; 48:1623-1627. [PMID: 28483358 DOI: 10.1016/j.injury.2017.04.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to observe the effects of induced membrane technique combined with two-stage internal fixation in the treatment of tibial osteomyelitis defects. METHODS A retrospective analyses for 67 cases of tibialosteomyelitis defects were admitted to our department between September 2012 to February 2015, which were treated with induced membrane technique. At the first stage, implanted with a PMMA cement spacer in the defects after radical debridement and fixed with reconstructive locked plate. Bone grafting and exchanged the plate with intramedullary nail at the second stage. RESULTS In current study, all patients were followed up for 18-35 months. Sixty-six patients achieved bone union with the average radiographic and clinical healing times of 5.55±2.19 and 7.45±1.69months, respectively. Seven patients required a second debridement before grafting, while four patients experienced a recurrence of infection or a relapse following second stage treatment. Twelve patients experienced either knee or ankle dysfunctions and 2 patients faced delayed wound healing. Donor site complications includes pain and infection were found in 7 and 3 patients, respectively with delayed stress fracture in 1 patient only. CONCLUSIONS Induced membrane technique for the treatment of tibial osteomyelitis defects, seems a reliable method. The use of reconstructive locked plate as a temporary internal fixation at the first stage and exchanged with intramedullary nail at the second stage, potentially achieves good clinical efficacy. Care should be taken to restore the joint function especially in distal tibia.
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Affiliation(s)
- Fei Luo
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
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Gindraux F, Rondot T, de Billy B, Zwetyenga N, Fricain JC, Pagnon A, Obert L. Similarities between induced membrane and amniotic membrane: Novelty for bone repair. Placenta 2017; 59:116-123. [PMID: 28673520 DOI: 10.1016/j.placenta.2017.06.340] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/30/2017] [Accepted: 06/21/2017] [Indexed: 02/06/2023]
Abstract
Previous clinical studies have shown the efficacy of a two-stage surgical procedure - the induced membrane (IM) technique - for reconstruction of large bone defects or bone non-union. The first stage involves radical debridement and insertion of a cement spacer into the bone defect. The second stage, performed weeks to months later, consists of removing the spacer while leaving the foreign body membrane induced by the cement in place, and then filling the cavity with bone autograft. The IM has been shown to (1) act as a protective physical barrier by preventing bone autograft resorption and (2) act as a bioreactor by promoting healing through revascularisation and growth factor secretion, and by concentrating mesenchymal stem cells (MSC) with osteogenic properties. New solutions to reduce this surgical procedure to a single step are being explored, for example by using an IM-like bioactive and protective barrier inserted into the bone defect at the same time as bone graft.
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Affiliation(s)
- Florelle Gindraux
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besancon, France; NanomedicineLab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.
| | - Thomas Rondot
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besancon, France
| | - Benoit de Billy
- NanomedicineLab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France; Paediatric Surgery Service, University Hospital of Besancon, France
| | - Narcisse Zwetyenga
- Department of Maxillofacial Surgery, Plastic - Reconstructive and Aesthetic Surgery, Hand Surgery, University Hospital of Dijon, France
| | | | | | - Laurent Obert
- Orthopaedic and Traumatology Surgery Service, University Hospital of Besancon, France; NanomedicineLab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
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Canavese F, Corradin M, Khan A, Mansour M, Rousset M, Samba A. Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:221-228. [PMID: 27644427 DOI: 10.1007/s00590-016-1859-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/09/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Chronic osteomyelitis and infected nonunion are relatively rare conditions in pediatric patients and are more frequently seen in developing countries. Although relatively rare, they are medically and surgically challenging. Here we report a novel surgical technique used to manage five patients with chronic osteomyelitis of long bones. METHODS Five skeletally immature patients with chronic osteomyelitis and infected nonunion of the long bones were treated surgically between 2010 and 2014 by a combination of resection of necrotic infected bone, debridement of surrounding soft tissue, and application of antibiotic-laden cement spacer inducing periosteal membrane before final bone reconstruction. Once inflammatory markers normalized, all the patients were re-operated for cement removal, bone graft substitution, and concomitant osteosynthesis of the affected bone, if needed. All patients underwent MRI, CT scan, and laboratory evaluation prior to surgery. The antibiotic regimen was started empirically and then adjusted according to culture and sensitivity results. RESULTS Mean patient age at the time of diagnosis was 11 years (range 4-14), and all patients had at least 2-year follow-up (range 2-5). At last follow-up, clinical and laboratory evaluation had normalized, the bone had healed, and all patients had resumed daily living and sports activities. CONCLUSION Surgical debridement is the standard approach to chronic osteomyelitis. Use of antibiotic-laden cement is recommended to penetrate local infection, with antibiotic therapy playing an adjunctive role. The cement also induces membrane formation that aids bone reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Federico Canavese
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France.
| | - Marco Corradin
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
| | - Ahmad Khan
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
| | - Mounira Mansour
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
| | - Marie Rousset
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
| | - Antoine Samba
- Pediatric Surgery Department, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
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