Early resection of congenital pseudarthrosis of the tibia and successful reconstruction using the Masquelet technique

Comparison of limb reconstruction with vascularized fibula flap versus induced membrane technique in 54 pediatric cases over 16 years

BACKGROUND

Children's bone loss of limbs represents a significant challenge for surgeons, especially given that children are growing individuals. In the pediatric population, we compared bone reconstruction using vascularized fibula flaps with the induced membrane technique. The primary purpose of this study was to evaluate the delay and quality of consolidation.

METHODS

Data from patients who underwent limb reconstruction using either the fibula flap or the induced membrane were retrospectively collected from files across two centers. Perioperative and long-term complications were documented, along with functional and aesthetic outcome.

RESULTS

Between 2004 and 2020, 31 children underwent limb reconstruction using a fibula flap, and 13 patients were treated using the induced membrane technique. The etiologies included 76% tumors, 20% congenital pseudarthroses, and 3.7% infections. The median size of the bone resection was 12.5 cm (range: 1.8 to 31 cm). The median time to consolidation after free fibula flap transfer was 10 months (range: 2 to 55 months) versus 7.5 months (range: 1 to 64 months) for the Masquelet technique (p = 0.54). Limb length inequality occurred in 52% of fibula cases and 39% of the induced membrane cases (p = 0.55).

CONCLUSIONS

Both of free fibula flap and the induced membrane technique are effective options for bone reconstructing long bones in children. These techniques yield good functional outcomes and have comparable consolidation times.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Clinical and radiological assessment of the induced membrane technique using beta-tricalcium phosphate in reconstructive surgery for lower extremity long bone defects

AIMS

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

METHODS

A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using β-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups.

RESULTS

There were ten and 25 defects in the femur and tibia, respectively. Median LEFS improved significantly from 8 (IQR 1.5 to 19.3) preoperatively to 63.5 (IQR 57 to 73.3) at final follow-up (p < 0.001). Bone healing was achieved in all limbs, and median time from the second stage to bone healing was six months (IQR 5 to 10). Median time to bone healing, preoperative LEFS, or postoperative LEFS did not differ significantly between the defect size groups or among the treatment groups.

CONCLUSION

IMT using β-TCP provided satisfactory clinical and radiological outcomes for segmental bone defects in the lower limbs; surgical outcomes were not influenced by bone defect size or operated part. Cite this article: Bone Joint J 2021;103-B(3):456-461.

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

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

Morphometric analyses of clavicle's nutrient foramen

PURPOSE

Fractures of the clavicle, which has an important location and function in the upper extremity and shoulder joint, compose 10% of all fracture cases. During the osteosynthesis of clavicle fractures and in the post-operative period of patients, considering the detailed morphometric and topographic properties of the nutrient foramen of clavicle is important to avoid the disruption of arterial nutrition of the clavicle and prevent unexpected injuries. The aim of this study was to investigate the morphometric properties of the nutrient foramen of clavicle in more detail using computedtomography images.

METHODS

Computed tomography images of 116 healthy individuals (56 women/60 men) who had no pathology history were included in the presented study. Computed tomography images were reconstructed three-dimensionally using free-licensed Horos v3.3.3 software. Then, distances from clavicle's nutrient foramen to sternal end, anterior and posterior edges of the clavicle were measured. Statistical analyses were completed using SPSS v21 software.

RESULTS

Our results demonstrated that the nutrient foramen of clavicle was located closer to the sternal end of the clavicle. The shortest distance to the sternal edge of clavicle was measured as 3.3 cm. Analyses of gender differences indicated that statistically significant differences were in favor of men. However, topographic properties of the clavicle's nutrient foramen were not affected by age.

CONCLUSION

Nutrient foramen is mostly located closer to the sternal end of clavicle. Especially during osteosynthesis of clavicle fractures at the sternal end, maintaining the arterial supply of clavicle is of great importance for increasing the post-operative life quality of patients.

Outcomes of Vacuum Sealing Drainage Treatment Combined with Skin Flap Transplantation and Antibiotic Bone Cement on Chronic Tibia Osteomyelitis: A Case Series Study

BACKGROUND Chronic osteomyelitis is one of the currently refractory diseases. The aim of this study is to discuss the method and curative effects of vacuum sealing drainage (VSD) treatment combined with skin flap transplantation and antibiotic bone cement for chronic tibia osteomyelitis. MATERIAL AND METHODS For this study, 18 cases of open fracture secondary chronic tibia osteomyelitis were selected. After the granulation tissue of the wound surface became fresh and infection was controlled, the wound surface was repaired with a medial head of gastrocnemius transfer flap or a myofascial and cutaneous island pedicle flap with a collateral vessel nourished by the retrograde sural nerve. VSD combined with focus debridement and antibiotic bone cement filling was conducted. After inflammation was completely regulated, elective bone cement extraction, bone grafting, and internal fixation were performed. Within 2 to 3 years of follow-up post-surgery, the satisfaction and recurrence rates were evaluated. The patients' pre-operative and post-operative recovery of limb functions were compared according to the Enneking scoring system. RESULTS The patients did not suffer from osteomyelitis recurrence, with the exception of 1 case that manifested osteomyelitis recurrence and recovered through surgical treatment within the period of follow-up. The satisfaction and recurrence rates of these study cases post-surgery were 94.4% and 5.6%, respectively. The average functional recovery post-surgery was 81.5% of normal function. CONCLUSIONS Vacuum sealing drainage combined with skin flap transplantation and antibiotic bone cement is an effective treatment for chronic tibia osteomyelitis.

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

BACKGROUND

Clavicular reconstruction in paediatric patients is a rarely performed procedure that often raises complex technical challenges and produces unreliable outcomes. The induced membrane technique is an innovative two-stage procedure involving cement spacer placement into the defect to induce the development of a membrane, followed by the implantation of a cortical-cancellous bone graft. The primary objective of this study was to assess the medium- and long-term clinical and radiographic outcomes of clavicular reconstruction using the induced membrane technique in children and to highlight the advantages and drawbacks of this technique. The secondary objectives were to evaluate the fixation and the outcomes according to age and to the underlying diagnosis.

HYPOTHESIS

Clavicular reconstruction using the induced membrane technique produces good outcomes in paediatric patients.

PATIENTS AND METHODS

The induced membrane technique was used for clavicular reconstruction in 4 children with a mean age of 9.7 years (range, 7.4-12.3 years). The diagnosis was congenital pseudarthrosis of the clavicle in 3 patients and aneurysmal bone cyst in 1 patient. Shoulder pain and mobility were assessed at last follow-up. Radiological bone healing was evaluated using the total radiographic union score (RUS, range, 0-10). Complications and number of procedures per patient were recorded.

RESULTS

Mean follow-up was 3.9 years (range, 1-8.4 years). None of the patients had pain or motion range limitation. After 6 months, the clavicle was healed with a RUS of 10 in all patients. The mean number of surgical procedures per patient was 3.75 (range, 3-5). Two patients required revision surgery for distal pin migration and another for a subcutaneous abscess under the pin.

DISCUSSION

When used for clavicular reconstruction, the induced membrane technique is effective and associated with a low complication rate. The induced membrane technique therefore deserves to be viewed as an alternative to other methods.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Masquelet Reconstruction for Posttraumatic Segmental Bone Defects in the Forearm

PURPOSE

The Masquelet technique is a procedure increasingly utilized for addressing segmental bone defects. The technique involves staged procedures consisting of bone debridement and temporary spacer placement to induce membrane formation, followed by delayed bone grafting. This report summarizes our center's experience with the Masquelet technique to reconstruct bone loss exclusively in the forearm.

METHODS

We reviewed all cases in which the Masquelet technique was used to reconstruct segmental bone defects in the forearm resulting from acute trauma or nonunion, with or without infection, between 2014 and 2017 at a level-1 trauma center. Injury mechanism, prior surgeries, extent of bone defect, and demographic data were collected. Union was assessed along with treatment-related complications or reoperations.

RESULTS

We identified 9 patients with segmental bony defects in the forearm treated with the Masquelet technique. Among this cohort, 5 patients had bone defects associated with acute open fractures and 4 patients presented with nonunion (1 atrophic and 3 infected nonunions). The median bony defect was 4.7 cm (range, 1.7-5.4 cm) at the time of grafting. Second stage grafting was performed with Reamer Irrigator Aspirator autograft from the femur in 8 patients and iliac crest bone cancellous graft in 1 patient. Union was achieved in all 9 patients. Six patients achieved union by 3-month follow-up, 2 patients by 6 months, and 1 patient by 12 months. One patient required a reoperation for plate fracture prior to union treated with revision internal fixation and grafting.

CONCLUSIONS

The Masquelet technique effectively reconstructed traumatic and posttraumatic segmental defects in the forearm with a low incidence of complication.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Short Term Results of a New Comprehensive Protocol for the Management of Congenital Pseudarthrosis of the Tibia

BACKGROUND

Treatment of Congenital Psuedarthrosis of Tibia (CPT) often poses significant challenges due to difficulty in achieving union and subsequent complications like refractures, implant failures, etc. Our new comprehensive protocol is aimed at achieving crossunion between the tibia and fibula.

AIMS AND OBJECTIVES

The aim of the present study is to evaluate the short-term results of our new protocol and to compare the results with our previously used techniques.

MATERIALS AND METHODS

10 patients with mean age 2.35 years (1 to 6.5 years) who were treated by our new comprehensive protocol were included in Group A, and 11 patients with mean age 2 years (1 to 5.5 years) who primarily underwent intramedullary rodding with bone graft were included in Group B. The new comprehensive protocol consisted of pre-operative Zolendronate infusion, surgery consisting of intramedullary fixation of tibia supplemented with Ilizarov ring fixator and bone grafting aimed at achieving tibia-fibula cross-union. Retrospective evaluation of serial radiographs was performed and outcomes with respect to union and subsequent complications were analysed.

RESULTS

10/10 (100%) patients in Group A united, whereas union was achieved in only 8/11 (72%) patients in Group B. The index surgery was successful in achieving union in all 10 patients in Group A, whereas in Group B 2.25 (1 to 4) surgeries were needed to achieve union. The time to union was significantly shorter in Group A (4.68 months) as compared to Group B (30.88 months). The cross sectional area of union was significantly greater in Group A (3.82 cm2) as compared to Group B (1.18 cm2). One patient in Group A needed a subsequent corrective osteotomy for tibial valgus, and one patient underwent tibia lengthening; whereas in Group B, two patients needed corrective osteotomes for residual malaligments.

CONCLUSION

Our study demonstrates that the new comprehensive protocol is extremely effective for achieving sound union in Congenital Pseudarthrosis of Tibia.

A pilot study: Alternative biomaterials in critical sized bone defect treatment

BACKGROUND

Critical-sized bone defects are a significant challenge with limited effective reconstructive options. The Masquelet Technique (MT) offers a solution to help restore form and function. Although this technique has produced promising results; a clear mechanism has not been determined. Theories include that the induced membrane has osteogenic potential or the membrane acts as a physical barrier to prevent fibrous tissue ingrowth. We hypothesize the induced membrane acts primarily as a physical barrier and that a synthetic non-biological membrane will allow a comparable amount of bone volume in the defect site.

METHODS

Ten New Zealand rabbit forelimbs (n=10) were divided into three study groups. A critical sized defect of 3.5cm in the ulna was created. In the control group, a traditional MT was performed (n=4). The experimental arm varied by replacement of the PMMA with a non-porous (n=3) or porous (150um) (n=3) polytetrafluoroethylene (PTFE) membrane filled with allograft. Micro-CT analysis was done to compare bone volume to tissue volume ratios (BV/TV). Defect sections were examined histologically with alkaline phosphatase (ALP), tartrate-resistant acid phosphatase (TRAP) and von kossa (VK) staining.

RESULTS

MicroCT analysis comparing BV/TV between the control and experimental arms showed no difference. BV/TV of the MT was 7.77%±2.34 compared to porous 9.12%±3.66 and nonporous 9.76%±1.57 PTFE membranes (p1=0.761, p2=0.572, respectively). Histological sections from both samples stained for ALP and TRAP displayed osteoblastic and osteoclastic activity. There was a higher amount of ALP and TRAP positively stained cells near the native bone ends in comparison to the center of the defect, in both sample types.

CONCLUSION AND SIGNIFICANCE

Replacing the induced membrane from the MT with a synthetic PTFE membrane illustrated that the membrane acts primarily as a functional barrier. Compared to the induced membrane, the PTFE membrane was able to display similar osteointegrative properties. These results allow for future optimization of the technique with the potential to further streamline towards a single stage procedure.

Congenital pseudarthrosis of the tibia in children: should we defer surgery until 3 years old?

Currently, the timing of surgery for congenital pseudarthrosis of the tibia (CPT) remains controversial. The aim of this study was to investigate the results of treatment of pseudarthrosis of the tibia in children younger than 3 years of age. A retrospective study was carried out to explore the relationship between postoperative complications and the age of surgery in children with CPT. The analysis was carried out on 42 patients with Crawford type IV CPT treated with a combined surgical technique between 2008 and 2012. Patients were divided into two groups according to their age: group A (<3 years) and group B (>3 years). The incidence rates of refracture, ankle valgus, tibial valgus, and limb-length discrepancy of the two groups were evaluated. Primary bone union was achieved in 28 out of 29 (97%) patients in group A and 12 out of 13 (92%) patients in group B (P>0.05). In group A, six (21%) patients developed a refracture; 14 (48%) patients had ankle valgus with a mean degree of 11° (range: 5°-25°); 11 (38%) patients had tibial valgus with a mean tibial valgus deformity of 8.6° (range: 5°-20°); and 12 (41%) patients had limb-length discrepancy with a mean limb length of 2.9 cm (range: 0.5-4 cm). In group B, five (38%) patients developed refracture; seven (54%) patients had ankle valgus with a mean degree of 14° (range: 5°-30°); seven (54%) patients had tibial valgus with a mean tibial valgus deformity of 10.7° (range: 5°-20°); and 10 (77%) patients had limb-length discrepancy with a mean limb length of 2.8 cm (range: 1.5-3 cm). Groups A and B were significantly different in limb-length discrepancy (P=0.033). This study suggests that there is no need to defer surgery for pseudarthrosis of the tibia until the child is older than 3 years of age.

Wrapping grafting for congenital pseudarthrosis of the tibia: A preliminary report

OBJECTIVE

Treatment of congenital pseudarthrosis of the tibia (CPT) remains a challenge. The autogenic iliac bone graft is important consistent of treatment for CPT. The purpose of this study was to investigate the role of wrapping autogenic iliac bone graft in improvement of the curing opportunities of CPT.

METHODS

We combined Ilizarov fixator with intramedullary rodding of the tibia and wrapping autogenic iliac bone graft for treatment 51 cases of CPT between 2007 and 2010. The mean age is 3.2 years at index operation, of which 31 patients (61%) were below 3 years old. According to Crawford classification, 5 tibia had type-II morphology; 3, type-III; 43, type-IV.

RESULTS

In the postoperative follow-up of 3.5 months (range from 3 to 4.5 months), all cases were found that the bone graft sites of pseudarthrosis of the tibia showed a significant augmentation and spindle-shaped expansion as obvious change. All cases of this series have been followed-up, average followed-up time were 1.6 years (range from 7 to 3.1 years), of which 19 cases were more than 2 years. The average time of removed the Ilizarov ring fixator was 3.5 months (range from 3 to 4.5 months). According to Johnston Clinical evaluation system, 26 cases had grade I, 21 cases, grade II, 4 cases, grade III. Following the Ohnishi X-ray evaluation criteria, union of pseudarthrosis of the tibia were 42 cases, delayed union 5 cases, nonunion 4 cases.

CONCLUSION

Autogenic iliac bone graft is able to offer the activity of osteoblasts and osteogenesis induced by bone morphogenetic protein (BMP) and glycoprotein, meanwhile enclosing bone graft could help keep cancellous bone fragments in close contact around pseudarthrosis of the tibia, allowing the formation of high concentration of glycoprotein and BMP induced by chemical factors because of established the sealing environment in location, all of which could enhance the healing of pseudarthrosis of the tibia.

Comparison of Monolateral External Fixation and Internal Fixation for Skeletal Stabilisation in the Management of Small Tibial Bone Defects following Successful Treatment of Chronic Osteomyelitis

Background

To compare the salvage rate and complication between internal fixation and external fixation in patients with small bone defects caused by chronic infectious osteomyelitis debridement.

Methods

125 patients with chronic infectious osteomyelitis of tibia fracture who underwent multiple irrigation, debridement procedure, and local/systemic antibiotics were enrolled. Bone defects, which were less than 4 cm, were treated with bone grafting using either internal fixation or monolateral external fixation. 12-month follow-up was conducted with an interval of 3 months to evaluate union of bone defect.

Results

Patients who underwent monolateral external fixation had higher body mass index and fasting blood glucose, longer time since injury, and larger bone defect compared with internal fixation. No significant difference was observed in incidence of complications (23.5% versus 19.3%), surgery time (156 ± 23 minutes versus 162 ± 21 minutes), and time to union (11.1 ± 3.0 months versus 10.9 ± 3.1 months) between external fixation and internal fixation. Internal fixation had no significant influence on the occurrence of postoperation complications after multivariate adjustment when compared with external fixation. Furthermore, patients who underwent internal fixation experienced higher level of daily living scales and lower level of anxiety.

Conclusions

It was relatively safe to use internal fixation for stabilization in osteomyelitis patients whose bone defects were less than 4 cm and infection was well controlled.

Congenital pseudarthrosis of the clavicle treated by Masquelet technique

Congenital pseudarthrosis of the clavicle (CPC) is a very rare pathology of which over 200 cases have been reported. Usually discovered during the first months of life, CPC is characterised by a definitive bone defect in the middle third of the clavicle. Generally asymptomatic, the pseudarthrosis of the clavicle can cause aesthetic issues and functional symptoms indicating a surgical repair. Different reconstruction techniques have been reported with various complications. We present a 14-year-old boy diagnosed with CPC and concerned about the cosmetic aspect of a swelling of his right clavicle. We performed a two-stage surgical repair using the induced membrane technique described by Masquelet. A complete bone union has been obtained, and patient is satisfied with the cosmetic appearance. In our opinion, the Masquelet technique is a safe and reproducible procedure to treat CPC in high-risk older patients with long gap allowing a rapid and lasting bone union.

Vascularised fibula or induced membrane to treat congenital pseudarthrosis of the Tibia: A multicentre study of 18 patients with a mean 9.5-year follow-up

BACKGROUND

The objective of this study was to compare outcomes of two surgical techniques used to treat congenital pseudarthrosis of the tibia (CPT), the induced membrane technique (IM) and the transfer of the contralateral vascularised fibula (VF).

HYPOTHESIS

The IM technique produces similar outcomes to those of VF grafting in terms of healing and function, while being simpler and having a lower complication rate.

MATERIAL AND METHOD

This retrospective multicentre study included 18 patients with a mean age of 2.8 years at surgery. Among them, 11 had neurofibromatosis type 1 (NF1). The IM technique was used in 10 patients and VF grafting in 8 patients. Mean follow-up was 9.5 years (range: 5-15 years).

RESULTS

The two groups showed no significant differences for healing or the occurrence of complications such as limb length discrepancy and residual malalignment. Two patients required amputation, one in each group. The mean number of surgical procedures per patient was 4.7 in the IM group and 5 in the VF group.

DISCUSSION

Outcomes are similar with the two techniques. Although VF grafting theoretically involves a single stage, the mean number of surgical procedures was not lower than after the IM technique. The IM technique was associated with lower risks of complications and residual donor site abnormalities. Regardless of the reconstruction technique, the quality of the initial bone resection and internal fixation, particularly regarding alignment, is of the utmost importance.

LEVEL OF EVIDENCE

IV, comparative retrospective study.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Relationship between postoperative complications and fibular integrity in congenital pseudarthrosis of the tibia in children

BACKGROUND

This study aimed to investigate the relationship between postoperative complications and fibular integrity in congenital pseudarthrosis of the tibia (CPT) in children.

METHODS

A retrospective study was performed in 59 patients with Crawford type IV CPT who were treated with combined surgical technique from 2007 to 2011. The patients were divided into two groups, the CPT with fibular pseudarthrosis (group A) and CPT with intact fibula groups (group B), on the basis of fibula status after the union of CPT. The incidence rates of refracture, ankle valgus, tibial valgus, and limb length discrepancy in the two groups were investigated.

RESULTS

In group A, 14 (36.8%) cases had refracture, 30 (78.9%) had ankle valgus; 27 (71%) exhibited tibial valgus with an average tibial valgus of 7° (6°-20°), and 24 (63.2%) had limb length discrepancy with an average limb length of 1.26 cm (0.6-4.4 cm). In group B, 2 (9.5%) cases had refracture, 11 (52.4%) had ankle valgus, 8 (42.9%) had tibial valgus with an average tibial valgus deformity of 2.9° (6°-13°), and 13 (61.9%) had limb length discrepancy with an average limb length of 1.48 cm (0.5-5 cm). Significant difference in refracture and ankle valgus was found between groups A and B (P<0.05).

CONCLUSIONS

After the union of CPT, patients with fibular pseudarthrosis showed higher incidence of refracture and ankle valgus than those with intact fibula. Attention should be paid to the presence of fibular pseudarthrosis when managing CPT.

Preliminary Results of the Induced Membrane Technique for the Reconstruction of Large Bone Defects

BACKGROUND

During past decades, gradual bone transplant using external fixators and vascularized fibular or rib transplants widely contributed to solve difficult problems related to the reconstruction of large bone defects in children. However, these surgeries are time consuming and require specialized surgical skills, not always available in a general hospital setting, mainly in rural areas.

PURPOSE

To report the preliminary results of the more recently described induced membrane technique in a consecutive series of 8 children and to identify some factors related to the procedure's success.

METHODS

Nine consecutive children with bone defects ranging from 5 to 14 cm were included in the study. The age at surgery ranged from 3 to 16 years. There were 3 congenital pseudarthrosis (CP) of the fibula, 1 CP of the tibia, 1 Ewing sarcoma of the tibia, 1 Ewing sarcoma of the ulna, 1 tibial osteosarcoma, 1 fibular osteosarcoma, and 1 chronic diffuse tibial osteomyelitis. The procedure was performed according to the original Masquelet's description in 2 stages. Follow-up ranged from 1 to 7 years.

RESULTS

The child with tibial osteosarcoma died 3 months after the surgery from complications related to chemotherapy. Among the 8 remaining children, 6 healed uneventfully, and 2 required revision with additional grafting and/or better internal fixation, one with Ewing sarcoma of the tibia and a 13-cm bone defect and the second with CP of the fibula. Both of them had suboptimal internal stabilization.

CONCLUSIONS

The induced membrane technique is a useful, efficient, and simple alternative to highly specialized surgical procedures used for the reconstruction of large bone defects in children. Risk factors for failure include chemotherapy, suboptimal bone fixation, and persistent axial malalignment.

LEVEL OF EVIDENCE

Level IV.

Success rate and risk factors of failure of the induced membrane technique in children: a systematic review

The induced membrane technique was designed by Masquelet et al. to address segmental bone defects of critical size in adults. It has been used after bone defects of traumatic, infectious and tumoral origin with satisfactory results. Recently, it has been used in children but, after an initial enthusiasm, several cases of failure have been reported. The purpose of this study was to assess the success rate and the risk factors of failure of the induced membrane for children. We conducted a systematic review of all the studies reporting the results of the induced membrane technique to address bone defects of critical size in children. Our primary outcome was the success rate of the technique defined as a bone union before any iterative surgery. Our secondary outcomes were the complications and the risk factors of failure. We searched Medline via Pubmed, EMBASE and the Cochrane Library. Twelve studies, including 69 patients, met the inclusion criteria. There were 41 boys and 28 girls. Mean age at surgery was 10 years. Mean size of resection was 12.38 cm and the mean time between the two stages was 5.86 months. Mean rate of bone union after the two stages of the induced membrane technique was 58% (40/69) but this rate increased to 87% after revision surgeries (60/69). Main complications were non-unions (19/69), lysis of the graft (6/69) and fractures of the bone graft (6/69). Only 1/69 deep infection was reported. Other non specific complications were regularly reported such limb length discrepancies, joint stiffness and protruding wires. Risk factor of failure that could be suspected comprised the resection of a malignant tumour, a bone defect located at the femur, a wide resection, a long time between the two stages, an unstable osteosynthesis and a bone graft associating autograft to other graft materials. The induced membrane technique is suitable for bone defects of critical size in children. It is a reliable technique with no need of micro vascular surgery. However, we found several risk factors of failure for the use of the induced membrane technique to address segmental bone defect of critical size in children.

Surgical technique and indications of the induced membrane procedure in children

The induced membrane technique is now quite adaptable to segmental bone reconstruction in children. This technique is much the same as the technique used in adults. A cement spacer is interposed, and in a second operating phase, occurring 6 weeks after the interposition of the spacer, the cement is removed and a morselized corticocancellous graft is installed in the induced membrane that had formed around the cement. Graft expansion using allograft chips should not exceed 30% of the total volume. An additional autograft strut is useful in the reconstruction of long femoral or metaphyseal-diaphyseal tibial defects. Despite the apparent simplicity of this technique, it requires rigorous technique during cement sleeving and to stabilize the defect to prevent nonunion, stabilization device loosening, or resorption of the graft, the main complications. This technique is now becoming the gold standard for bone reconstruction in trauma and septic bone surgery. In pediatrics, the Masquelet technique is now mainly used in the context of cancer surgery reconstructions. Constraints related to chemotherapy have led to deferral of the graft, which is therefore empirically performed 8 weeks after the last course of chemotherapy. Congenital anomalies, including congenital pseudarthrosis, may now be treated using this technique, replacing long and difficult conventional treatment. A longer follow-up would be necessary to assess and confirm the superiority of this pediatric reconstruction technique.

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

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

Management of congenital pseudarthrosis of the tibia with the Ilizarov method in a paediatric population: influence of aetiological factors

PURPOSE

Our study compared the rates of union achieved with the Ilizarov method in congenital pseudarthrosis of the tibia (CPT) associated with neurofibromatosis type 1 (NF1) or CPT of idiopathic origin in paediatric patients.

METHODS

We studied the outcomes of 28 children that were treated for CPT between 2005 and 2013. Group 1 included children (n = 14, mean age = 9.7 years) with CPT associated with NF1 while group 2 were CPT cases that had radiographic confirmation of dysplastic lesions in the tibia but lacked clinical NF1 manifestations (n = 14, mean age = 8.6 years). There was no statistical difference between the groups regarding their age or number of previous operations per patient. Individual technical solutions were planned for each patient but coaptation of bone fragments and autologous local tissue grafting to achieve a greater bone thickness and contact area at the pseudarthrosis level were mainly used. Refracture-free rate after the first operation, number of re-operations per patient, and union rates in the groups were compared.

RESULTS

Bone union and weight bearing were obtained in all the cases after the first operation. Refracture-free rate was 42.86 % in group 1 and 35.71% in group 2 (no statistical difference, p > 0.05). Mean number of re-operations per patient was 1.07 and 0.78 respectively (p > 0.05). Subsequent treatment for refractures with the Ilizarov techniques gained 92.86% of union in both groups at the follow-ups by completion of the study (range, 2-9 years).

CONCLUSIONS

The Ilizarov method yields comparable results in the management of CPT associated with NF1 or tibial dysplasia of idiopathic origin in paediatric cases. Further research should focus on the ways to support the Ilizarov method in order to reduce the number of repetitive surgeries or eliminate them.

Osteoclasts and their precursors are present in the induced-membrane during bone reconstruction using the Masquelet technique

In 2000, Masquelet reported a long bone reconstruction technique using an induced membrane formed around a polymethylmethacrylate (PMMA) spacer placed in the defect with appropriate stabilization followed by secondary bone graft after PMMA removal. This reconstruction procedure allows rapid and safe bone reformation for septic, traumatic, neoplastic or congenital bone defects. A rat model of the Masquelet technique was developed to further characterize the biological activities of this induced membrane. Our model allows healing of a critical-sized femoral defect (8 mm) by means of this procedure over a period of 18 weeks. Comparison of induced membranes obtained 3, 4, 5 and 6 weeks after PMMA insertion indicated that this tissue changes over time. Several mineralization spots and bone cells were observed in contact with the PMMA, when assessed by Alizarin Red, Von Kossa, Alkaline phosphatase and Tartrate-resistant acid phosphatase staining of the membranes. CTR (calcitonin receptor)- and RANK (Receptor Activator of Nuclear factor Kappa B)- positive mononuclear cells were detected in the induced membrane, confirming the presence of osteoclasts in this tissue. These cells were observed in a thin, highly cellular layer in the induced membrane in contact with the PMMA. Together, these findings suggest that the membrane is able to promote osteointegration of autologous corticocancellous bone grafts during the Masquelet technique by creating local conditions that may be favourable to graft bone remodelling and osteointegration. Copyright © 2014 John Wiley & Sons, Ltd.

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

The literature regarding reconstruction of foot bone defects is limited. The purpose of this study is to present a case report with an extensive bone defect of the first metatarsal bone which was treated with the use of the induced membrane technique. A 53-year-old man, with comminuted foot grade IIIb open fracture was treated with the Masquelet procedure. At 14 months follow-up, clinical and radiological assessment of the foot revealed osseous healing and no signs of infection, osteolysis or hardware failure. At 18 months follow-up, the patient had no pain and returned to his usual daily activities. The Masquelet procedure provides an effective method of treatment of extensive bone defects of the foot. It can restore the normal length and metatarsal arch minimizing the risk of complications that occurs with other surgical procedures.

LEVEL OF EVIDENCE

Level V, case report.

Induced membrane technique for the treatment of congenital pseudarthrosis of the tibia: preliminary results of five cases

PURPOSE

The purpose of this study was to evaluate the two-stage surgical technique combining induced membrane, spongy autograft and intramedullary fixation for the treatment of congenital pseudarthrosis of the tibia (CPT).

METHODS

Three boys and two girls were treated by this technique between 2003 and 2008. All patients had type IV CPT in Crawford's classification. Four of them had a limited dystrophic form, whereas one case presented an extensive tibia bone dystrophy. The average age of patients at the time of surgery was 23 months (range 10-30 months), with an average follow-up of 5.8 years (range 2.4-8.1 years).

RESULTS

Satisfactory tibial bony union was achieved in all cases at the last follow-up. Bone healing was obtained in the four limited forms after an average term of 4 months. One patient suffered from a non-displaced fracture that healed by casting in a usual period of time. The patient with an extensive dystrophic bone had to undergo a secondary inter-tibiofibular bone graft to finally achieve bone union.

CONCLUSIONS

The preliminary results show that this technique is successful in CPT. It may be used even in young children and offers a good alternative to other treatments available, avoiding external fixation and the technical difficulties of microvascular surgery.

Bone defect reconstruction in children using the induced membrane technique: a series of 14 cases

INTRODUCTION

In pediatrics, Masquelet's induced membrane reconstructive technique has mainly been used in the context of cancer surgery reconstruction or congenital pseudarthrosis of the tibia. This retrospective study consisted of a series of pediatric patients where bone defects were reconstructed with this technique.

MATERIALS AND METHODS

Between 2006 and 2011, 14 children underwent bone reconstruction using this technique in the context of trauma, tumor resection or congenital pseudarthrosis. The mean age was 10.6years (range: 12 to 17years) at the time of reconstruction. The length of the defect to be reconstructed relative to the length of the bone (index of reconstruction, expressed as a percentage) and bone healing was evaluated on standard radiographs. Complications were recorded.

RESULTS

The mean index of reconstruction was 32.8% (range: 13.9 to 51%). The mean follow-up was 30months (range: 1 to 63). Bone union was achieved in 9.5months (range: 2 to 25). Complications mainly consisted of non-union in 35% of cases, which consolidated after grafting and rigid fixation. Two cases of wound dehiscence were noted. Massive graft resorption occurred in a single case.

DISCUSSION

A technical error was identified in each non-union case (insufficient cement overlap of the bone ends or fixation not stiff enough). These long defects required a large volume of autograft, which constitutes the limiting factor especially in very young children. We used allograft bone chips or a tibial bone strut to increase the graft volume in the largest reconstructions. In this pediatric-only series, an average of one-third of the bone length was successfully reconstructed. Although the technique appears simple, it must be performed rigorously to ensure the cement sufficiently overlaps the bone ends and the defect is properly stabilized to prevent non-union, which is the main complication.

LEVEL OF EVIDENCE

Level IV (retrospective study).

Advances on the Masquelet technique using a cage and nail construct

Traumatic, cancerous or infectious loss of bone is treated by either amputation or reconstruction. With limb salvage always preferable, surgeons rely on already established techniques such as grafting and distraction osteogenesis to avoid amputation, and ideally restore structure and thus function. The Masquelet technique is an effective method of bone reconstruction and limb salvage which is underreported in the English literature, and we report a case with advances using a cage and nail construct, resulting in successful eradication of methicillin resistant staphylococcus aureus infection and reconstitution of a 17 cm diaphyseal defect in the tibia.

Congenital pseudarthrosis of the tibia: Management and complications

Congenital pseudarthrosis of the tibia (CPT) is a rare pathology, which is usually associated with neurofibromatosis type I. The natural history of the disease is extremely unfavorable and once a fracture occurs, there is a little or no tendency for the lesion to heal spontaneously. It is challenging to treat effectively this difficult condition and its possible complications. Treatment is mainly surgical and it aims to obtain a long term bone union, to prevent limb length discrepancies, to avoid mechanical axis deviation, soft tissue lesions, nearby joint stiffness, and pathological fracture. The key to get primary union is to excise hamartomatous tissue and pathological periosteum. Age at surgery, status of fibula, associated shortening, and deformities of leg and ankle play significant role in primary union and residual challenges after primary healing. Unfortunately, none of invasive and noninvasive methods have proven their superiority. Surgical options such as intramedullary nailing, vascularized fibula graft, and external fixator, have shown equivocal success rate in achieving primary union although they are often associated with acceptable results. Amputation must be reserved for failed reconstruction, severe limb length discrepancy and gross deformities of leg and ankle. Distinct advantages, complications, and limitation of each primary treatment as well as strategies to deal with potential complications have been described. Each child with CPT must be followed up till skeletal maturity to identify and rectify residual problems after primary healing.