A load-sharing nail - cage construct may improve outcome after induced membrane technique for segmental tibial defects

Engineering the bone reconstruction surgery: the case of the masquelet-induced membrane technique

The reconstruction of large bone defects remains challenging for orthopedic surgeons. Autologous bone grafts (ABGs) are the gold standard treatment for limited size defects, but larger bone defects (> 5 cm) require the use of more sophisticated techniques, such as the Masquelet technique. Over the last three decades, the Masquelet or induced membrane technique (IMT) has become increasingly popular as it does not require high-precision microsurgery skills and the time taken to achieve bone consolidation is independent of the length of the defect. IMT is a two-stage procedure. In the first stage, a polymethylmethacrylate (PMMA) cement spacer is implanted into the bone lesion and a physiological immune reaction initiates the formation of a fibrotic induced membrane (IM) with both angiogenic and osteogenic properties. The second stage, performed several weeks later, involves removal of the spacer followed by the implantation of a standard ABG in the preserved IM cavity for subsequent bone repair. In this extensive review, we explain how the success of this surgical procedure can be attributed to the synergy of four key components: the inducer (the PMMA cement), the recipient (the IM), the effector (the bone graft) and the modulator (the mechanical environment). Conversely, we then explain how each key component can contribute to the failure of such treatment. Finally, we discuss existing or emerging innovative and biotechnology-oriented strategies for optimizing surgical outcome with respect to the four components of IMT described above.

Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft? A scoping review

PURPOSE

Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment.

METHODS

A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing.

RESULTS

Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient.

CONCLUSION

Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon's expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects ( ≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.

Ilizarov method and its combined methods in the treatment of long bone defects of the lower extremity: systematic review and meta-analysis

BACKGROUND

Ilizarov method has become one of primary methods for treating bone defects. Currently, there is growing trend in the application of modified Ilizarov methods (e.g., applying unilateral external fixators or with flap tissue) and its combined methods (e.g., Ilizarov method with antibiotic spacer or internal fixation) to manage bone defects. However, there is a lack of studies with systematical evaluation of the clinical effects of these evolving methods. This study aimed to conduct a systematic review and meta-analysis for overall evaluating the clinical effects on long bone defects of lower extremity in Ilizarov methods and its combined methods.

METHODS

Studies were identified in three electronic databases (Pubmed, Embase and Cochrane Library) from the earliest indexing year through November 01, 2022, and relevant data were extracted subsequently. The total number of participants, number of participants with bone unions, bone result or functional result, and related complications including pin infection, pin loosening, pain, refracture, limb discrepancy, malalignment, joint stiffness, recurrent infection, and amputation were extracted in this study. Then, union rate (defined as the proportion of patients who achieved bone unions) and specific complication incidence rate (defined as the proportion of patients who experienced specific complication) were pooled estimated respectively. Relative risk (RR) was used for comparing the clinical effects among various Ilizarov technique.

RESULTS

Sixty-eight case series studies, 29 comparative studies, and 3 randomized clinical trials were finally included. The union rate of Ilizarov methods was 99.29% (95% CI: 98.67% ~ 99.86%) in tibial defects and 98.81% (95% CI: 98.81% ~ 100.00%) in femoral defects. The union rate of Ilizarov method with antibiotic spacer and intramedullary nail in tibial defects was 99.58% (95% CI: 98.05% ~ 100.00%) and 95.02% (95% CI: 87.28% ~ 100.00%), respectively. Compared to the Ilizarov methods, the union rate of the Ilizarov method with antibiotic spacer in tibial defects increased slightly (RR = 1.02, 95% CI: 1.01 ~ 1.04). Meanwhile, compared to Ilizarov methods, we found lower excellent rate in bone result in Ilizarov method with antibiotic spacer, with the moderate to high heterogeneity. Compared to the Ilizarov method, lower rate of pin infection, higher rate of recurrent infection and amputation were observed in Ilizarov method with intramedullary nail, however, the findings about the comparison of pin infection and recurrent infection between the two groups were presented with high degree of statistical heterogeneity.

CONCLUSION

Our study confirmed the reliable treatment of Ilizarov methods and its combined technique on long bone defects, and founded there were significant differences on some complications rate between Ilizarov methods and its combined technique. However, the findings need to be confirmed by further studies.

Validation of the Polish versions of the Lower Limb Task Questionnaire, Lower Limb Functional Index, and Lower Limb Functional Index-10

BACKGROUND

Physicians who treat patients with lower limb diseases should pay attention not only to the patients' clinical condition but also to their individual needs and expectations. For this purpose, many different questionnaires can be employed. This study aimed to validate the Lower Limb Task Questionnaire (LLTQ), Lower Limb Functional Index (LLFI), and Lower Limb Functional Index-10 (LLFI-10) for their use in Polish conditions and to perform a mutual comparison and analysis of differences in subjective assessments by patients who undergo hip or knee arthroplasty.

METHODS

The LLTQ, LLFI, and LLFI-10 were translated into Polish. A total of 103 patients who qualified for hip or knee arthroplasty at a University Hospital in from 2019 to 2021 were included in this study. The patients were asked to complete the Polish versions of the LLTQ, LLFI, LLFI-10, Lower Extremity Functional Scale (LEFS), and Short Form-36 four times - twice before and twice after their surgeries.

RESULTS

The Polish versions of the LLTQ, LLFI, and LLFI-10 had good psychometric properties. One year after surgery, the Cohen's standard response mean revealed high improvement of limb functionality and thus quality of life among all patients. We observed better treatment outcomes among patients who had hip osteoarthritis.

CONCLUSIONS

The questionnaires were validated and can be used both in everyday health practice and in further research in Poland.

Masquelet Technique for the Tibia: A Systematic Review and Meta-Analysis of Contemporary Outcomes

OBJECTIVE

To systematically review outcomes of the Masquelet "induced membrane" technique (MT) in treatment of tibial segmental bone loss and to assess the impact of defect size on union rate when using this procedure.

DATA SOURCES

PubMed, EBSCO, Cochrane, and SCOPUS were searched for English language studies from January 1, 2010, through December 31, 2019.

STUDY SELECTION

Studies describing the MT procedure performed in tibiae of 5 or more adult patients were included. Pseudo-arthrosis, nonhuman, pediatric, technique, nontibial bone defect, and non-English studies were excluded, along with studies with less than 5 patients. Selection adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

DATA EXTRACTION

A total of 30 studies with 643 tibiae were included in this meta-analysis. Two reviewers systematically screened titles or abstracts, followed by full texts, to ensure quality, accuracy, and consensus among authors for inclusion or exclusion criteria of the studies. In case of disagreement, articles were read in full to assess their eligibility by the senior author. Study quality was assessed using previously reported criteria.

DATA SYNTHESIS

Meta-analysis was performed with random-effects models and meta-regression. A meta-analytic estimate of union rate independent of defect size when using the MT in the tibia was 84% (95% CI, 79%-88%). There was no statistically significant association between defect size and union rate ( P = 0.11).

CONCLUSIONS

The MT is an effective method for the treatment of segmental bone loss in the tibia and can be successful even for large defects. Future work is needed to better understand the patient-specific factors most strongly associated with MT success and complications.

LEVEL OF EVIDENCE

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

Functional outcomes and health-related quality of life after reconstruction of segmental bone loss in femur and tibia using the induced membrane technique

INTRODUCTION

The induced membrane technique (IMT), frequently called Masquelet technique, is an operative, two-staged technique for treatment of segmental bone loss. Previous studies mainly focused on radiological outcome parameters and complication rates, while functional outcomes and health-related quality of life after the IMT were sparsely reported.

MATERIALS AND METHODS

Retrospective study containing of a chart review as well as a clinical and radiological follow-up examination of all patients treated with the IMT at a single institution. The clinical outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the Short-Form-36 (SF-36) and the visual analog scale (VAS) for pain. The radiographic evaluation contained of standard anteroposterior and lateral, as well as hip-knee-ankle (HKA) radiographs.

RESULTS

Seventeen patients were included in the study. All had suffered high-energy trauma and sustained additional injuries. Ten bone defects were localized in the femur and seven in the tibia. Ten patients underwent additional operative procedures after IMT stage 2, among them three patients who contracted a postoperative deep infection. The median LEFS was 59 (15-80), and the SF-36 physical component summary (PCS) and mental component summary (MCS) were 41.3 (24.0-56.1) and 56.3 (13.5-66.2), respectively. The median length of the bone defect was 9 (3-15) cm. In 11 patients, union was obtained directly after IMT stage 2. Bone resorption was observed in two patients. At follow-up, 16 of the 17 bone defects had healed. The median follow-up was 59 months (13-177).

CONCLUSION

Our results show a high occurrence of complications after IMT stage 2 in segmental bone defects of femur and tibia requiring additional operative procedures. However, fair functional outcomes as well as a good union rate were observed at follow-up.

The clinical application of customized 3D-printed porous tantalum scaffolds combined with Masquelet’s induced membrane technique to reconstruct infective segmental femoral defect

Purpose

This study mainly exams a novel treatment for infective segmental femoral defect, and we combined the 3D printed porous tantalum prosthesis and Masquelet’s induce membrane technique to reconstruct bone defect and discussed the clinical effect.

Method

The clinical research included 9 observational cases series, as a permanently implantation, the customized 3D-printed scaffolds that connected with an anatomical plate was implanted into the bone defect segment after successful formation of induced membrane, the clinical effect was evaluated by radiological exams and Paley’s bone union criteria.

Result

The personalized 3D-printed porous tantalum was, respectively, manufactured and used in 9 consecutive patients to reconstruct the infective segmental bone defect of femur, the mean defect length was 16.1 ± 2.8 cm, the mean length of follow-up was 16.9 ± 4.0 months, after 2 stage operation, there was no deep infections, refractures, sensorimotor disorder, vascular injury, ankylosis and recurrence of infection occurred in all cases. postoperative radiological exams shown stable internal fixation and osseointegration, and all these results were invariable during the follow-up time in all cases. All patients significantly obtained deformity correction and length of limb.

Conclusion

The customized 3D-printed porous tantalum prosthesis was an acceptable alternative treatment to the autogenous or allograft bone graft, the combination of the two techniques could achieve satisfactory reconstruct to infective broad bone defect in femur when other biological techniques were not suitable.

Treatment of Critical-Sized Bone Defects Involving the Ankle Joints: Staged Tibiotalocalcaneal Arthrodesis With Induced Membrane Technique and Intramedullary Nail

OBJECTIVES

To report the outcomes of staged tibiotalocalcaneal (TTC) arthrodesis for critical-sized bone defects involving the ankle joints.

DESIGN

Retrospective review of case series.

SETTING

Two academic Level 1 trauma centers.

PATIENTS/PARTICIPANTS

The study included 20 patients with critical-sized (≥2 cm) segmental bone defects around the ankle joints.

INTERVENTION

Staged TTC arthrodesis was performed with induced membrane technique and retrograde intramedullary nail.

MAIN OUTCOME MEASUREMENTS

We investigated the radiological evaluation, including modified radiographic union scale for tibia fractures score, time to union, and leg length discrepancy, and functional outcomes using foot and ankle outcome score and American Orthopaedic Foot and Ankle Society ankle-hindfoot score.

RESULTS

The average bone defect was 6.4 cm (range: 2.4-12.3). Two of the 20 (10%) patients developed recurrence of infection. Fifteen patients (75%) achieved primary healing. Three patients (15%) were treated with repeated bone grafting and additional plating. The average time to union and leg length discrepancy were 10 months (range: 5-21) and 9 mm (range: 0-31), respectively. The mean foot and ankle outcome score and American Orthopaedic Foot and Ankle Society ankle-hindfoot score were 63 (range: 52-71) and 74 (range: 64-81), respectively.

CONCLUSIONS

Staged TTC arthrodesis with induced membrane technique and intramedullary nail can be an effective treatment method for critical-sized bone defects involving the ankle joints.

LEVEL OF EVIDENCE

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

The efficacy of combining a vascularized biogenic conduit and a decellularized nerve graft in the treatment of peripheral nerve defects: An experimental study using the rat sciatic nerve defect model

BACKGROUND

Although decellularized nerve grafts are often used as a bridging material in nerve defect repair, the lack of perfusion support in this procedure limits the regeneration capacity. To address this, we applied vascularized biogenic conduits, which are fibrous membranes prefabricated around the silicone rod that contain rich vascularity and macrophages, to nerve defect repair procedures using decellularized nerve grafts. The purpose of this study is to investigate the capacity of combining a vascularized biogenic conduit and a decellularized nerve graft for peripheral nerve regeneration using a 10-mm nerve defect model in rats.

MATERIALS AND METHODS

Sixteen adult male rats (F344 rats, 10-12 weeks, 200-250 g) were used in this study. For the prefabrication of vascularized biogenic conduits, a silicone rod was transplanted next to the sciatic nerve. After 8 weeks, this silicone rod was enveloped in connective tissue, called a vascularized biogenic conduit. The first rat was used to investigate the histological characteristics of vascularized biogenic conduits through immunofluorescence studies. The remaining 15 rats were divided into three groups to evaluate the efficacy of the combination of a decellularized nerve graft and a vascularized biogenic conduit: a decellularized nerve graft (DNG) group, a decellularized nerve graft with a vascularized biogenic conduit (DNG-w-VBC) group, and an autologous nerve graft (ANG) group. Eight weeks after nerve graft surgery, the assessment results of both functional recovery (electrophysical studies and target muscle atrophy) and morphological recovery (total number, diameter, and myelin thickness of the regenerated axons) of the regenerated nerves were examined.

RESULTS

Immunofluorescence studies revealed that the VBC contains extracellular matrix, vascular tissue, and macrophages. The results of the DNG-w-VBC group were superior to the DNG group in electrophysiological studies (CMAP; 6.29 ± 0.80% vs. 4.02 ± 3.35%, MNCV; 50.6 ± 8.4% vs. 25.7 ± 15.6%, p < .05, respectively), regenerated axon number (11,348 ± 812 vs. 7697 ± 2197, p < .05), and mean axon diameter (2.72 ± 0.33 μm vs. 1.64 ± 0.12 μm, p < .05).

CONCLUSIONS

Our study confirms that vascularized biogenic conduits supply vascularity and macrophages to nerve defect sites. Combining vascularized biogenic conduits with decellularized nerve grafts to treat nerve defects offers superior functional and morphological recovery of regenerated axons.