Bone defect treatment: does the type and properties of the spacer affect the induction of Masquelet membrane? Evidence today

Evaluation of the comparative efficacy and safety of surgical strategies for long bone defects: a network meta-analysis

BACKGROUND

To evaluate the safety and efficacy of various surgical treatments for long bone defects. Despite numerous observational studies, randomized controlled trials (RCTs), and meta-analyses, the optimal surgical treatment for long bone defects remains undetermined.

METHODS

A network meta-analysis (NMA) was conducted. PubMed, Embase, and the Cochrane Library were searched for articles published between 1 January 2000 and 12 January 2023 on surgical treatments for long bone defects. RCTs and observational studies comparing five surgical treatments were selected: the Masquelet technique (MT), bone transport (BT), vascularized bone graft (VBG), non-VBG (NVBG), and bone tissue engineering (BTE). Data were extracted by two independent reviewers. The NMA aggregated direct and indirect evidence. Treatments were ranked using the surface under the cumulative ranking curve (SUCRA) scores. Data are presented as mean differences and 95% confidence intervals. The primary outcomes were the postoperative healing rate, with subgroup analysis based on defect size (4-8 cm and >8 cm). The secondary outcomes included postoperative complications.

RESULTS

This NMA included 23 studies (three RCTs and 20 observational studies) with 930 participants (median age, 35 years). There were no significant differences in clinical outcomes among the treatments. VBG (SUCRA, 75.1%) was rated as optimal for healing, and BTE (SUCRA, 28.5%) was the least effective. BTE had the highest complication rate (SUCRA, 90.9%), whereas NVBG had the lowest complication rate (SUCRA, 27.6%). Subgroup analysis showed reduced heterogeneity: for 4-8 cm defects, VBG (SUCRA, 80.4%) was optimal, and for >8 cm defects, BT (SUCRA, 76.2%) was optimal.

CONCLUSIONS

VBG and BT may offer superior clinical outcomes for long bone defects compared to MT, NVBG, and BTE. However, BTE is associated with a high risk of complications. Further high-quality, large-sample RCTs are required to confirm these findings.

Construction of a 3D Degradable PLLA/β-TCP/CS Scaffold for Establishing an Induced Membrane Inspired by the Modified Single-Stage Masquelet Technique

Although the Masquelet-induced membrane technique (MIMT) is now employed worldwide for bone defects, it often needs to be repeated and autogenous bone graft. This study aims to investigate the theoretical feasibility of replacing PMMA (poly(methyl methacrylate)) bone cement with PLLA (poly-l-lactic acid)/β -TCP (beta-tricalcium phosphate)/CS (calcium sulfate) scaffold for single-stage bone defect reconstruction, which evoke the induced membrane (IM) formation in the early stage and directly acts as the implantation in the second stage to reconstruct the bone defect. We constructed a corn-like PLLA/β -TCP/CS scaffold by the fused deposition 3D printing method. The characterizations of the scaffolds were investigated systematically. The P/T15/S15 scaffolds (the PLLA/β -TCP/CS scaffold with a 15% mass fraction of β-TCP and 15% mass fraction of CS) were filled into the large-segmental radius bone defects of white rabbits to evoke the formation of IMs. HE (hematoxylin-eosin) and VG (van gieson) staining, along with immunofluorescent staining, were performed to analyze the architecture and cellularity, the expression of BMP-2 (bone morphogenetic protein-2), VEGF (vascular endothelial growth factor), and TGF-β1 (transforming growth factor-β1) was evaluated by IHC (immunohistochemistry) and WB (western-blot) respectively, the ALP (alkaline phosphatase) and ARS (alizarin red S) staining was applied to assess the osteogenic potential. The corn-like PLLA/β-TCP/CS scaffolds with excellent physicochemical properties are successfully constructed using the fused deposition 3D printing technique. The HE and VG staining, along with immunofluorescent staining, suggested that the P/T15/S15 scaffold effectively mediated the formation of IM after 6 weeks of placement. A significant presence of M2 macrophages was observed in IM. The results of IHC and WB demonstrated that the IMs derived from the P/T15/S15 scaffolds exhibited elevated levels of VEGF, BMP-2, and TGF-β1, all of which promote the osteogenic differentiation of BMSCs. The results of cellular immunofluorescence, flow cytometry, and WB indicate that P/T15/S15 regulates the phenotypic polarization of M0 macrophages toward the M2 phenotype via the PI3K/AKT/β-Catenin pathway. These findings suggest that the biodegradable PLLA/β-TCP/CS scaffold may serve as a viable alternative to PMMA bone cement for single-stage bone defect reconstruction, owing to its unique ability to stimulate IM formation and promote the polarization of macrophages toward the M2 phenotype. This work presents innovative materials and strategies for the management of bone defects.

Masquelet technique combined with concentrated growth factors for the reconstruction of rabbit mandibular marginal bone defect

OBJECTIVE

Both the Masquelet technique (MT) and concentrated growth factors (CGF) reduce early graft loss and improve bone regeneration. This study aims to explore the efficacy of combining MT with CGF for mandibular defect repair by characterizing the induced membrane and assessing in vivo osteogenesis.

MATERIALS AND METHODS

Three experimental groups were compared: negative control (NC), MT, and Masquelet combined with CGF (MTC). Four weeks after the first surgery, histopathology is used to identify the morphological structure of the induced membrane, evaluate the degree of vascularization, and the secretion levels of osteogenesis and angiogenesis-related growth factors. In vivo osteogenesis was assessed with a second autologous bone graft surgery 4 weeks later, and bone reconstruction was evaluated by micro-CT and histopathology.

RESULTS

CGF significantly increased the induced membrane thickness, vascularization, and growth factor secretion levels. Quantitative micro-CT analysis showed that the bone volume fraction (BV/TV) at 4 weeks post-surgery was higher in the MTC group (23.30 ± 1.15%) compared to the MT group (16.50 ± 1.29%) and NC group (12.62 ± 1.23%) (P < 0.05). By 12 weeks, the difference in BV/TV between MTC (32.59 ± 0.11%) and MT (29.89 ± 0.49%) reduced, indicating consistent bone regeneration. Trabecular parameters were consistently higher in the MTC group, highlighting enhanced osteogenesis.

CONCLUSION

Combining the Masquelet technique with CGF effectively reduces early bone graft absorption and promotes bone repair. These findings suggest potential benefits for oral and maxillofacial bone defect treatment, though further studies are needed to confirm long-term efficacy.

CLINICAL RELEVANCE

Integrating Masquelet technique and CGF in mandibular reconstruction may improve clinical outcomes by enhancing bone regeneration and reducing graft failure.

[Modified Masquelet technique : Technique of the induced membrane in the course of time]

The reconstruction of long bone defects as a result of primary traumatic, secondary infection or tumor-related loss of substance continues to represent a surgical challenge. Callus distraction via segment transport, vascularized bone transfer and the induced membrane technique (IMT) are established methods of reconstruction. In recent decades IMT has experienced increasing popularity due to its practicability, reproducibility and reliability. At the same time, the original technique has undergone numerous modifications. The results are correspondingly heterogeneous. This overview is intended to explain the basic principles of IMT and to provide an overview of the various modifications and their complications.

PMMA-induced biofilm promotes Schwann cells migration and proliferation mediated by EGF/Tnc/FN1 to improve sciatic nerve defect

Objective

The purpose of this study is to investigate the role of PMMA-induced biofilm in nerve regeneration compared with silicone-induced biofilm involved in the mechanism.

Methods

PMMA or silicon rods were placed next to the sciatic nerve to induce a biological membrane which was assayed by PCR, Western blot, immunohistochemistry, immunofluorescence and proteomics. A 10 mm sciatic nerve gaps were repaired with the autologous nerve wrapped in an induced biological membrane. The repair effects were observed through general observation, functional evaluation of nerve regeneration, ultrasound examination, neural electrophysiology, the wet weight ratio of bilateral pretibial muscle and histological evaluation. Cell proliferation and migration of Schwann cells co-cultured with EGF-treated fibroblasts combined with siRNA were investigated.

Results

The results indicated that expression of GDNF, NGF and VEGF along with neovascularization was similar in the silicone and PMMA group and as the highest at 6 weeks after operation. Nerve injury repair mediated by toluidine blue and S100β/NF200 expression, the sensory and motor function evaluation, ultrasound, target organ muscle wet-weight ratio, percentage of collagen fiber, electromyography and histochemical staining were not different between the two groups and better than blank group. EGF-treated fibroblasts promoted proliferation and migration may be Tnc expression dependently.

Conclusion

Our study suggested that PMMA similar to silicon induced biofilm may promote autogenous nerve transplantation to repair nerve defects through EGF/Tnc/FN1 to increase Schwann cells proliferation and migration.

Human Acellular Collagen Matrices-Clinical Opportunities in Tissue Replacement

The field of regenerative medicine is increasingly in need of effective and biocompatible materials for tissue engineering. Human acellular dermal matrix (hADM)-derived collagen matrices stand out as a particularly promising candidate. Their ability to preserve structural integrity, coupled with exceptional biocompatibility, positions them as a viable choice for tissue replacement. However, their clinical application has been largely confined to serving as scaffolds. This study aims to expand the horizon of clinical uses for collagen sheets by exploring the diverse cutting-edge clinical demands. This review illustrates the clinical utilizations of collagen sheets beyond traditional roles, such as covering skin defects or acting solely as scaffolds. In particular, the potential of Epiflex®, a commercially available and immediately clinically usable allogeneic membrane, will be evaluated. Collagen sheets have demonstrated efficacy in bone reconstruction, where they can substitute the induced Masquelet membrane in a single-stage procedure, proving to be clinically effective and safe. The application of these membranes allow the reconstruction of substantial tissue defects, without requiring extensive plastic reconstructive surgery. Additionally, they are found to be apt for addressing osteochondritis dissecans lesions and for ligament reconstruction in the carpus. The compelling clinical examples showcased in this study affirm that the applications of human ADM extend significantly beyond its initial use for skin defect treatments. hADM has proven to be highly successful and well-tolerated in managing various etiologies of bone and soft tissue defects, enhancing patient care outcomes. In particular, the application from the shelf reduces the need for additional surgery or donor site defects.

Bone reconstruction with modified Masquelet technique in open distal femoral fractures: a case series

BACKGROUND

Large bone defects require complex treatment, multidisciplinary resources, and expert input, with surgical procedures ranging from reconstruction and salvage to amputation. The aim of this study was to provide the results of a case series of open comminuted intra-articular distal femoral fractures with significant bone loss that were managed by early fixation using anatomical plates and a modified Masquelet technique with the addition of surgical propylene mesh.

METHODS

This retrospective study included all patients referred to our institution with OTA/AO C3 distal femur open fractures and meta-diaphyseal large bone loss between April 2019 and February 2021. We treated the fractures with irrigation and debridement, acute primary screw and plate fixation in the second look operation, and Masquelet method using shell-shaped antibiotic beads supplemented by propylene surgical mesh to keep the cements in place. The second step of the procedure was conducted six to eight weeks later with bone grafting and mesh augmentation to contain bone grafts. Surprisingly, hard callus formation was observed in all patients at the time of the second stage of Masquelet procedure.

RESULTS

All five patients' articular and meta-diaphyseal fractures with bone loss healed without major complications. The average union time was 159 days. The mean knee range of motion was 5-95 degrees. The average Lower Extremity Functional Score (LEFS) was 49 out of 80.

CONCLUSIONS

Combination of early plate fixation and the modified Masquelet technique with polypropylene mesh is an effective method for managing large bone defects in open intra-articular distal femoral fractures with bone loss, resulting in shorter union time possibly associated with the callus formation process. This technique may also be applicable to the management of other similar fractures specially in low-income and developing areas.

Measuring Bone Healing: Parameters and Scores in Comparison

(1) Background: Bone healing is a complex process that can not be replicated in its entirety in vitro. Research on bone healing still requires the animal model. The critical size femur defect (CSFD) in rats is a well-established model for fractures in humans that exceed the self-healing potential. New therapeutic approaches can be tested here in vivo. Histological, biomechanical, and radiological parameters are usually collected and interpreted. However, it is not yet clear to what extent they correlate with each other and how necessary it is to record all parameters. (2) Methods: The basis for this study was data from three animal model studies evaluating bone healing. The µCT and histological (Movat pentachrome, osteocalcin) datasets/images were reevaluated and correlation analyses were then performed. Two image processing procedures were compared in the analysis of the image data. (3) Results: There was a significant correlation between the histologically determined bone fraction (Movat pentachrome staining) and bending stiffness. Bone fraction determined by osteocalcin showed no prognostic value. (4) Conclusions: The evaluation of the image datasets using ImageJ is sufficient and simpler than the combination of both programs. Determination of the bone fraction using Movat pentachrome staining allows conclusions to be drawn about the biomechanics of the bone. A standardized procedure with the ImageJ software is recommended for determining the bone proportion.

[Biological reconstruction of large bone defects : Masquelet technique and new procedures]

Extensive diaphyseal and metaphyseal bone defects continue to pose a major challenge for orthopedic trauma surgeons. Various treatment options have been described for the biological reconstruction of these defects. The most frequently used methods are bone segment transport, the Masquelet technique and 3D printed scaffolds. As far as the Masquelet technique is concerned, in the first stage spacers, such as polymethyl methacrylate (PMMA), calcium sulfate or polypropylene are inserted into the bone defects to induce a foreign body membrane. In the second stage the bone defect surrounded by the induced membrane is filled with autologous cancellous bone. The time interval between the first and second interventions is usually 4-8 weeks whereby the induced membranes do not lose their bioactivity even with a latency period longer than 8 weeks. Three-dimensional printed scaffolds are increasingly used but large clinical studies are lacking in order to show the exact role of this procedure in the reconstruction of bone defects.

The antibiotics supplemented bone cement improved the masquelet's induced membrane in a rat femur critical size defect model

BACKGROUND

Masquelet technique is a two-stage surgical procedure used in the treatment of critical-size bone defects (CSD). Adding antibiotics to polymethylmethacrylate (PMMA) is still questionable to create higher quality induced membrane (IM). The aim of the study was to evaluate the effects of three antibiotic-supplemented cement, fusidic acid, teicoplanin, and gentamicin, on osteogenesis and IM progression applied to rat femur CSD model by comparing histopathological, biochemical, and immunohistochemical findings.

METHODS

Twenty-eight male rats were divided into four groups control, gentamicin (G), teicoplanin (T), and fusidic acid (FA). A 10 mm CSD was created in rat femurs. In the postoperative 4th week, intracardiac blood samples were collected for biochemical analysis of bone alkaline phosphatase (BALP), osteocalcin (OC), and tumor necrosis factor-alpha (TNF-α) levels. IMs obtained in secondary operation were fixed and prepared for histopathological scoring of membrane progression and immunohistochemical evaluation of rat-specific Transforming Growth Factor-Beta (TGF-β), Runt-related Transcription Factor 2 (Runx2), and Vascular Endothelial Growth Factor (VEGF) expressions.

RESULTS

Levels of BALP and OC in serum didn't change among groups significantly while serum TNF-α levels significantly decreased in all antibiotic groups compared to the control group (P = 0.017). Histological scores of groups FA and T were significantly higher than those of groups Control and G (P = 0.0007). IMs of groups T and FA showed good progression while those of groups Control and G were also moderately progressed. A significant increase in TGF-β expression was observed in group G and FA (P = 0.001) while a significant increase in the expression of VEGF was observed in groups G and T compared to the control group (P = 0.036).

CONCLUSIONS

The bone cement impregnated with thermostable and safe antibiotics, gentamicin, fusidic acid, and teicoplanin can increase osteogenesis and support IM progression by increasing the expressions of TGF-β and VEGF. Anabolic effects of induced membranes used in the treatment of critical-size bone defects can be enhanced by antibiotic-supplemented PMMAs applied by altering the original technique.

Time-varying characteristics of the induced membrane and its effects on bone defect repair

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.

Influence of the Immune Microenvironment Provided by Implanted Biomaterials on the Biological Properties of Masquelet-Induced Membranes in Rats: Metakaolin as an Alternative Spacer

Macrophages play a key role in the inflammatory phase of wound repair and foreign body reactions-two important processes in the Masquelet-induced membrane technique for extremity reconstruction. The macrophage response depends largely on the nature of the biomaterials implanted. However, little is known about the influence of the macrophage microenvironment on the osteogenic properties of the induced membrane or subsequent bone regeneration. We used metakaolin, an immunogenic material, as an alternative spacer to standard polymethylmethacrylate (PMMA) in a Masquelet model in rats. Four weeks after implantation, the PMMA- and metakaolin-induced membranes were harvested, and their osteogenic properties and macrophage microenvironments were investigated by histology, immunohistochemistry, mass spectroscopy and gene expression analysis. The metakaolin spacer induced membranes with higher levels of two potent pro-osteogenic factors, transforming growth factor-β (TGF-β) and bone morphogenic protein-2 (BMP-2). These alternative membranes thus had greater osteogenic activity, which was accompanied by a significant expansion of the total macrophage population, including both the M1-like and M2-like subtypes. Microcomputed tomographic analysis showed that metakaolin-induced membranes supported bone regeneration more effectively than PMMA-induced membranes through better callus properties (+58%), although this difference was not significant. This study provides the first evidence of the influence of the immune microenvironment on the osteogenic properties of the induced membranes.