Interest of nailing associated with the Masquelet technique in reconstruction of bone defect

Evaluation of safety and efficacy of the bone marrow mesenchymal stem cell and gelatin-nano-hydroxyapatite combination in canine femoral defect repair

Femoral shaft fracture is a common bone trauma in dogs. The limitation of mesenchymal stem cells in bone defect applications is that the cell suspension cannot be fixed to the bone defect site. In the study, our objective was to substantiate the combined application of canine bone marrow mesenchymal stem cells (cBMSCs) and gelatin-nano-hydroxyapatite (Gel-nHAP) and evaluate its therapeutic effect on bone defect diseases in dogs. Experiments were performed to evaluate the following: (1) the porosity of Gel-nHAP; (2) the adhesion of cBMSCs to Gel-nHAP; and (3) the effect of Gel-nHAP on cBMSC proliferation. The efficacy and safety of the combination of cBMSC and Gel-nHAP in the repair of femoral shaft defects were evaluated in animal experiments. The results showed that Gel-nHAP supported the attachment of cBMSCs and exhibited good biocompatibility. In the animal bone defect repair experiment, significant cortical bone growth was observed in the Gel-nHAP group at week 8 (p < 0.05) and in the cBMSCs-Gel-nHAP group at week 4 (p < 0.01). We demonstrated that Gel-nHAP could promote the repair of bone defects, and the effect of cBMSC-Gel-nHAP on the repair of bone defects was profound.

Definitive fixation in the first stage of the induced membrane technique for septic segmental bone defects. Why not?

Background

Infected segmental bone defects (I-SBD) are challenging and complex to manage. This study aimed to show the outcomes achieved in I-SBD of the femur and tibia, treated with the induced membrane technique performing a definitive bone stabilization in the first stage.

Methods

We retrospectively reviewed 30 patients with infected non-articular segmental bone defects of the femur (n = 11) and tibia (n = 19), operated consecutively between January 2015 and May 2021. The need for fixation exchange, bone defect length, allo/autograft ratio used, bone healing, reoperation (discriminating between mechanical and infection-related causes), and failure rates (graft resorption or nonunion) were recorded.

Results

Fixation in the first stage was performed with 28 (93.33%) intramedullary nails, ten coated with antibiotic cement, and 2 (6.67%) locked plates. None were removed during the second stage of the technique. The mean length of the bone defects was 5cm (range 3.5-12). The most commonly used allo-/autograft ratio was 50-50. The bone healing rate was 93.33% (n = 28), with a median follow-up of 7 months (range 3-12). The reoperation rate due to mechanical instability was 3.33% (n = 1) and for recurrence of infection was 10.0% (n = 3). The overall failure rate was 6.67% (n = 2). The median follow-up was 42 months (range 12-85).

Conclusion

Masquelet technique appears feasible and effective in treating infected segmental bone defects of the femur and tibia. Definitive fixation at the first stage showed a success rate of 93.33%, with a re-operation rate of 10.0% related to infection.

Induced Membrane Technique for the Management of Segmental Femoral Defects: A Systematic Review and Meta-Analysis of Individual Participant Data

Several modifications of the induced membrane technique (IMT) have been reported, but there is no consensus regarding their results and prognosis. Moreover, most studies have focused on tibial defects; no meta-analysis of the treatment of femoral defects using the IMT has been reported. This systematic review and meta-analysis aimed to identify the potential risk factors of post-procedural complications following the treatment of segmental femoral defects using the IMT. A comprehensive search was performed on the Cochrane Library, EBSCO, EMBASE, Ovid, PubMed, Scopus, and Web of Science databases, using the keywords "femur," "Masquelet technique," and "induced membrane technique." Original articles composed in English, having accessible individual patient data, and reporting more than two cases of bony defect or nonunion of femur or more than five cases of any body part were included. Post-procedural bone graft infections, final union status, and union time after second-stage operation were analyzed. Fourteen reports, including 90 patients, were used in this study. External fixation in second-stage surgery had an odds ratio of 9.267 for post-procedural bone graft infection (p = 0.047). The odds ratio of post-procedural bone graft infection and age >65 years for final non-union status was 51.05 (p = 0.003) and 9.18 (p = 0.042). Shorter union time was related to impregnated antibiotics in the spacer (p = 0.005), transplanting all-autologous grafts (p = 0.042), and the application of intramedullary nails as the second-stage fixation method (p = 0.050). The IMT appears to be reasonable and reproducible for femoral segmental bone defects. Several preoperative and surgical factors may affect post-procedural complications and union time.

Ilizarov bone transport combined with the Masquelet technique for bone defects of various etiologies (preliminary results)

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.

Use of Tantalum Trabecular Metal Cones for Management of Nonunion of the Distal Femur with Segmental Bone Defects: Technique and Case Series

Introduction:

Segmental bone loss in the distal femur presents a challenge for reconstruction regardless of etiology. Use of tantalum trabecular metal cones with intramedullary fixation and autologous bone graft may be used as a salvage technique in difficult situations where other options have either been exhausted or are unavailable.

Case Report:

Surgical planning and technique for this approach to reconstruction are described. A retrospective review of five cases with >1 year of follow-up was performed to provide radiographic and clinical outcomes. All five patients had satisfactory outcomes with clinical union and retention of implants at final follow-up (average >4 years).

Conclusions:

Use of tantalum metal cones for reconstruction of distal femur nonunion with segmental bone defects can be a successful technique in a complex group of patients.

Modified Masquelet Technique Using Allogeneic Graft for a Gustilo-Anderson Type III-A Open Fracture of the Femur with an 8 cm Bone Defect

The induced membrane technique was initially described by Masquelet et al. in 1986 as a treatment for tibia nonunion; then, it became one of the established methods in the management of bone defects. Several changes have been made to this technique and have been used in different contexts and different methodologies. We present the case of a 16-year-old girl admitted to our department for a polytrauma after a motorcycle accident. She presented a Gustilo III-A open fracture of the right femoral shaft with a large bone defect of 8 centimeters that we treated with a modified Masquelet technique. In the first stage, an Open Reduction and Internal Fixation of the fracture was made using a 4,5 mm Dynamic Compression Plate and a PMMA cement was inserted at the bone defect area. The second stage was done after 11 weeks, and the defect area was filled exclusively with bone allograft from a bone bank. Complete bony union was seen at 60 weeks of follow-up. After the removal of the implants by another surgeon, the patient presented an atraumatic fracture of the neoformed bone that we treated with intramedullary femoral nailing associated with a local autograft using reaming debris. A complete bony union was achieved after 12 weeks with a complete range of motion of the hip and knee. The stability given to the fracture is essential because it influences the quality of the induced membrane and Masquelet has recommended high initial fixation rigidity to promote incorporation of the graft. It is recommended to delay the second stage of this technique after 8 weeks, especially in femoral reconstruction, to optimize the quality of the induced membrane. Several studies used a modified induced membrane technique to recreate a traumatic large bone defect, and all of them used an autologous bone graft alone or an enriched bone graft. In this case, the use of allograft exclusively seems to be as successful as an autologous or enriched bone graft. Now, with the advent of bone banks, it is possible to get an unlimited amount of allograft, so additional research and large studies are necessary before giving recommendations.

Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: a retrospective study of 19 cases

Background

The incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis.

Methods

We retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed.

Results

A total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55 months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively.

Conclusion

Intramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.

Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects

PURPOSE

To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT).

METHODS

A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2.

RESULTS

Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence.

CONCLUSIONS

Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.