SURGICAL TECHNIQUE
Masquelet Technique for Treatment of Segmental Bone Loss in the Upper Extremity Alan J. Micev, MD, David M. Kalainov, MD, Alexander P. Soneru, MD
C
URRENT MANAGEMENT OPTIONS for reconstruction of large segmental bone defects in the upper extremity include structural bone grafting with nonvascularized autografts, vascularized autografts, allografts, distraction osteogenesis, and insertion of bioactive materials.1e5 Nonvascularized autografts require a well-perfused recipient site for successful implantation, and there is an inherent potential for resorption with grafts longer than a few centimeters. Vascularized bone grafts have an improved rate of survival in a poorly vascularized bed; nevertheless, graft site morbidity is a potential drawback and the operation requires microvascular skills. The use of structural allografts will eliminate donor site morbidity, but can be complicated by infection, incomplete remodeling, fracture, and disease transmission. Distraction osteogenesis involves making a corticotomy while preserving the surrounding periosteum and gradually lengthening the bone segments.6,7 Specialized equipment is required and the transport of bone is limited to approximately one mm per day with 2e3 days of consolidation required for each day of distraction. Biological growth factors such as bone morphogenetic protein-2 and platelet-derived growth
From the Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. Received for publication August 25, 2014; accepted in revised form December 5, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David M. Kalainov, MD, Northwestern Center for Surgery of the Hand, 737 N. Michigan Ave., Suite 700, Chicago, IL 60611; e-mail: [email protected]. 0363-5023/15/4003-0033$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.12.007
factor can stimulate the formation of mature and mechanically competent bone, although the best combinations of these signaling proteins and the ideal carrier substances for timely release remain under investigation.8 Autologous bone grafting within induced granulation tissue membranes, otherwise known as the Masquelet technique, is a relatively simple method of treating segmental bone defects in the upper and lower extremities.9e20 The technique is applicable to both aseptic and septic conditions leading to substantial bone loss and requires no advanced skills in microvascular surgery. In the first stage, a thorough debridement is performed, the segmental bone defect is bridged by a tubularized construct of methylmethacrylate, and the bone is stabilized by orthopedic hardware. A thin fibrous membrane forms around the cement spacer within 4 weeks. In a second operation, the cement spacer is removed while preserving the membrane and the contained void is filled with cancellous autograft. This grafting method is capable of addressing segmental bone defects in the limbs measuring several centimeters in length with reported union rates of 82% to 100%.11 The majority of publications in the English and French literature pertain to use of the Masquelet technique in the treatment of segmental bone defects in the lower extremities. There are few full reports of managing bone defects in the upper extremities,10,11,13,20 supporting our observation that this approach has not become widely used by hand surgeons. We describe the basic principles of this technique and present a case example in which an infected radial shaft fracture was effectively treated. The patient consented to have data concerning her case submitted for publication.
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
593
Surgical Technique
A relatively simple technique to address large segmental bone defects in the upper extremity is described, along with a case example. (J Hand Surg Am. 2015;40(3):593e598. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Induced membrane, Masquelet technique, bone grafting, segmental bone defect, osteomyelitis.
594
INDUCED-MEMBRANE BONE GRAFTING
Surgical Technique FIGURE 1: A Posteroanterior and B lateral radiographs of the left forearm 6 weeks after injury and repair showing loosening of both fracture fixation implants and resorption of bone in the radial shaft.
INDICATIONS AND CONTRAINDICATIONS The Masquelet technique can be utilized in the treatment of epiphyseal, metaphyseal, or diaphyseal bone loss secondary to tumor, trauma, or infection with segmental defects measuring up to 25 cm in length.13 The technique can also be performed in conjunction with management of soft tissue deficiencies. Poor patient compliance is an absolute contraindication to the operation. Relative contraindications include massive tissue necrosis, radiation, chronic systemic steroid use, smoking, and malnutrition, all of which which may inhibit bone healing.
more than one surgical debridement and temporary stabilization of the osseous defect may be indicated before definitive fixation and insertion of a cement spacer. Impregnating methylmethacrylate with a powdered antibiotic targeted at a known or suspected pathogen may assist in sterilization of the wound. The use of a cement spacer in this fashion has been previously described and is analogous to the application of antibiotic beads in the treatment of osteomyelitis.10,11,19 After 4 weeks, the resultant thin fibrous membrane is incised and the cement spacer is removed en bloc or piecemeal. The rigidity of the orthopedic fixation construct is assessed and carefully augmented or revised in the event of loosening. The induced membrane is made of a type 1 collagen-heavy matrix with fibroblastic cells and contains high concentrations of growth and osteogenic factors.11,15,17 The contained void is filled with morsellized cancellous autograft, an abundant amount of which can be obtained from the iliac crest or femoral canal, and the slit in the membrane is closed.5,16 Cancellous allograft and demineralized bone matrix can be added as
SURGICAL TECHNIQUE In the first stage, the wound is thoroughly debrided of devitalized tissue, the bone ends are freshened to bleeding tissue, and the intramedullary canals are drilled for a limited distance to promote increased vascularity. The bone is then stabilized, preferably with a plate and screws, and the void is filled with a tubularized construct of methylmethacrylate. In the event of a grossly contaminated or infected wound, or both, J Hand Surg Am.
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FIGURE 2: A Intra-operative picture of the left radius immediately after debridement of necrotic bone, revision plate fixation, and insertion of an antibiotic-impregnated cement spacer. B Posteroanterior radiograph of the left forearm showing the revision construct.
FIGURE 3: A Intra-operative picture of the induced fibrous membrane after removal of the cement spacer and before insertion of the bone graft. B Posteroanterior and C lateral radiographs of the left forearm showing well-contained bone graft.
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extenders, if the volume of cancellous autograft is insufficient. The membrane protects against autograft bone resorption and soft-tissue interposition and serves as a barrier to outward diffusion of growth and osteoinductive factors during the course of bone healing.11,12 The eventual shape of the healed bone graft will be defined by the dimensions of the membrane.
Surgical Technique
POSTOPERATIVE MANAGEMENT The extremity is protected by restricting load bearing, and a splint may be utilized at the discretion of the treating surgeon. Application of an external bonegrowth stimulator can be considered, although there are no reports validating the benefit of this technology in combination with the Masquelet technique. Serial radiographs and clinical examination are effective means of assessing bone healing. Computerized tomography examination of the graft site is our preferred method of confirming graft consolidation. PEARLS, PITFALLS, AND COMPLICATIONS Some authors have recommended molding the cement spacer over the bone ends in order to ensure continuity of the induced membrane.11,17 Temporarily removing the spacer during the final stage of cement polymerization may prevent heat damage to the bone and surrounding soft tissue. Securing the spacer to the overlying plate with a screw will inhibit migration. Two recent studies have suggested an optimal time of 4 weeks for bone grafting into the induced membrane. In a random sample of 14 patients undergoing the Masquelet technique, Aho et al9 found that vascularization in membranes was greatest at 1 month and decreased to less than 60% in 3-month-old samples. One-month old samples had the highest expression of vascular endothelial growth factor, interleukin-6, and type-1 collagen expression, whereas 2-month old membranes expressed less than 40% of the levels of 1-month old membranes. Markers of stemcell differentiation into the osteoblastic lineage were also greater in 1-month-old membranes in comparison with 2-month old membranes. Pelissier et al15 studied the induced-membrane technique in rabbits and found that bone morphogenetic protein-2 production peaked at 4 weeks after cement implantation and gradually declined over the ensuing month. Several authors have recognized a lag to bone bridging after grafting into an induced membrane. In a series of 35 cases described by Masquelet et al,13 the average time to full weight bearing after grafting segmental defects in the upper and lower extremities J Hand Surg Am.
FIGURE 4: Computerized tomography image of the left forearm 8 months after bone grafting of the radial shaft defect showing a small triangular lucency in the midregion of the graft.
was 8.5 months (range, 6e17 mo). Delays to graft consolidation in other studies have ranged from 3 to 18 months.11 Consequently, this technique may not be appropriate in cases where a potentially more rapid restorative approach is desired, such as a vascularized bone transfer.2,3 Packing a large mass of graft too tightly may potentially impede revascularization, and a graft composition containing more than 25% of a volume extender may conceivably slow bone healing.11,17 The occasional need for repeat bone grafting to address a delayed or nonunion has been reported.19 Other potential problems with the Masquelet technique include loosening of the fixation implant, infection, fracture through the graft, and bone resorption. A fracture through the graft may occur before the complete corticalization of bone, a process that can take more than one year. This risk of fracture is potentially greater with use of external fixation in comparison with intramedullary nails or plate-andscrew constructs.17 Graft resorption was recently reported in 3 children who underwent induced-membrane reconstruction after excision of malignant bone tumors from the r
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FIGURE 5: A Lateral radiograph and B computed tomography image of the left forearm one year after repeat bone grafting showing consolidation of the graft.
plate fixation of both diaphyseal fractures (Fig. 2A,B). There was no gross purulence. The cement spacer was removed after a 4.5-week course of intravenous antibiotic treatment directed at a polymicrobial infection, and a cylindrical fibrous membrane spanning the bone defect was filled with a mixture of autogenous cancellous bone from the contralateral iliac crest, allograft bone chips, and demineralized bone matrix (Fig. 3AeC). Intravenous antibiotic treatment was continued for an additional 1.5 weeks, and the repeat intraoperative cultures showed no organismal growth. The ulna healed within 8 weeks, whereas an asymptomatic atrophic nonunion in the midregion of the radial bone graft was discerned by computerized tomography imaging 9 months later (Fig. 4), despite rigid splinting and application of a pulsed electromagnetic field bone growth stimulator device (Biomet EBI Bone Healing System, Parsippany, NJ). The defect was treated by insertion of additional autogenous cancellous bone harvested from the ipsilateral olecranon process, splinting, and continued application of the bone healing stimulator. Intraoperative cultures were again negative. A repeat computed tomography scan 6 months later showed progressive but incomplete bone healing. Another computed
femur.21 The authors acknowledged that some of the recommendations made by the developers of the Masquelet technique were not followed. Hypotheses put forward to explain bone resorption included a 6to 7-month delay between insertion of the cement spacer and bone grafting, suboptimal implant stability, the considerable size of each reconstructed defect, the use of excessive allograft in comparison to autograft, and possible tumor recurrence or infection. CASE EXAMPLE An 18-year-old track athlete sustained an open left diaphyseal both-bone forearm fracture in a pole vaulting event that was initially treated by emergent wound debridement and plate fixation. She presented for a second opinion 6 weeks later with persistent forearm pain and swelling. Imaging studies revealed failure of implant fixation and suspected osteomyelitis of the radial shaft with segmental bone loss (Fig. 1A,B). A 2-stage reconstruction technique was undertaken with the first stage involving debridement of necrotic and infected bone, implantation of an antibiotic-impregnated (tobramycin and vancomycin) cement spacer to span a 4.5-cm segmental defect in the radial shaft, and revision J Hand Surg Am.
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Surgical Technique
tomography scan one year after repeat bone grafting (22 mo after the first stage of the Masquelet technique) showed bone consolidation (Fig. 5A,B). The patient was able to return to competitive hurdling one year after the initial debridement procedure and pole vaulting after confirmation of graft consolidation. The induced membrane technique is an effective tool to address large segmental bone defects in the upper extremity. The method is particularly useful in cases of concomitant bone loss and infection and does not require the treating surgeon to be skilled in microvascular techniques. The membrane delivers growth and osteoinductive factors and promotes the revascularization and maturation of cancellous bone. Studies support an optimal time period of 4 weeks between insertion of the cement spacer and exchange of the cement spacer for bone graft. A delay in graft consolidation from several months to more than one year is expected and should be considered when deciding upon the appropriateness of this technique for each patient under consideration.
7.
8.
9.
10.
11.
12.
13.
14.
15.
ACKNOWLEDGMENTS The authors would like to thank Dr. Thomas A. Wiedrich for assisting in the care of the patient presented.
16.
REFERENCES
17.
1. DeCoster TA, Gehlert RJ, Mikola EA, Pirela-Cruz MA. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg. 2004;12(1):28e38. 2. Gan AWT, Puhaindran ME, Pho RWH. The reconstruction of large bone defects in the upper limb. Injury. 2013;44(3):313e317. 3. Gaskill TR, Urbaniak JR, Aldridge JM III. Free vascularized fibular transfer for femoral head osteonecrosis: donor site and graft site morbidity. J Bone Joint Surg Am. 2009;91(8):1861e1867. 4. Khan SN, Cammisa FP, Harvinder SS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad Orthop Surg. 2005;13(1):77e86. 5. Myeroff C, Archdeacon M. Autogenous bone graft: donor sites and techniques. J Bone Joint Surg Am. 2011;93(23):2227e2236. 6. Rigal S, Merloz P, Le Nen D, Mathevon H, Masquelet AC, the French Society of Orthopaedic Surgery and Traumatology (SoFCOT).
J Hand Surg Am.
18.
19.
20.
21.
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Bone transport techniques in posttraumatic bone defects. Orthop Traumatol Surg Res. 2012;98(1):103e108. Seitz WH, Shimko P, Patterson RW. Long-term results of callus distraction-lengthening in the hand and upper extremity for traumatic and congenital skeletal deficiencies. J Bone Joint Surg Am. 2010;92(Suppl 2):47e58. Shah NJ, Hyder N, Quadir MA, et al. Adaptive growth delivery from a polyelectrolyte coating promotes synergistic bone tissue repair and reconstruction. Proc Natl Acad Sci USA. 2014;111(35):12847e12852. Aho O, Lehenkari P, Ristiniemi J, Lehtonen S, Risteli J, Leskela H. The mechanism of action of induced membranes in bone repair. J Bone Joint Surg Am. 2013;95(7):597e604. Flamans B, Pauchot J, Petit H, et al. [Use of the induced membrane technique for the treatment of bone defects in the hand or wrist, in emergency]. Chir Main. 2010;29(5):307e314. Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R. Masquelet technique for the treatment of bone defects: tips, tricks and future directions. Injury. 2011;42(6):591e598. Klaue K, Knothe U, Anton C, et al. Bone regeneration in long-bone defects: tissue compartmentalization? In vivo study on bone defects in sheep. Injury. 2009;40(Suppl 4):S95eS102. Masquelet AC, Fitoussi F, Begue T, Muller GP. [Reconstruction of the long bones by the induced membrane and spongy autograft]. Ann Chir Plast Esthet. 2000;45(3):346e353. Masquelet AC, Gegue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am. 2010;41(1):27e37. Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res. 2004;22(1):73e79. Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and Masquelet technique for segmental bone defect nonunions: a review of 25 cases. Injury. 2010;41(Suppl 2):S72eS77. Taylor BC, French BG, Fowler TT, Russell J, Poka A. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg. 2012;20(3):142e150. Viateau V, Bensidhoum M, Guillemin G, et al. Use of the induced membrane technique for bone tissue engineering purposes: animal studies. Orthop Clin North Am. 2010;41(1):49e56. Woon CY, Chong KW, Wong M. Induced membranes—a staged technique of bone grafting for segmental bone loss. J Bone Joint Surg Am. 2010;92(1):196e201. Zappaterra T, Ghislandi X, Adam A, et al. [Induced membrane technique for the reconstruction of bone defects in the upper limb. A prospective single center study of nine cases]. Chir Main. 2011;30(4):255e263. Accadbled F, Mazeau P, Chotel F, Cottalorda J, Sales de Gauzy J, Kohler R. Induced-membrane femur reconstruction after resection of bone malignancies: three cases of massive graft resorption in children. Orthop Traumatol Surg Res. 2013;99(4):479e483.
Vol. 40, March 2015
Masquelet Technique for Treatment of Segmental Bone Loss in the Upper Extremity Alan J. Micev, MD, David M. Kalainov, MD, Alexander P. Soneru, MD
C
URRENT MANAGEMENT OPTIONS for reconstruction of large segmental bone defects in the upper extremity include structural bone grafting with nonvascularized autografts, vascularized autografts, allografts, distraction osteogenesis, and insertion of bioactive materials.1e5 Nonvascularized autografts require a well-perfused recipient site for successful implantation, and there is an inherent potential for resorption with grafts longer than a few centimeters. Vascularized bone grafts have an improved rate of survival in a poorly vascularized bed; nevertheless, graft site morbidity is a potential drawback and the operation requires microvascular skills. The use of structural allografts will eliminate donor site morbidity, but can be complicated by infection, incomplete remodeling, fracture, and disease transmission. Distraction osteogenesis involves making a corticotomy while preserving the surrounding periosteum and gradually lengthening the bone segments.6,7 Specialized equipment is required and the transport of bone is limited to approximately one mm per day with 2e3 days of consolidation required for each day of distraction. Biological growth factors such as bone morphogenetic protein-2 and platelet-derived growth
From the Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. Received for publication August 25, 2014; accepted in revised form December 5, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David M. Kalainov, MD, Northwestern Center for Surgery of the Hand, 737 N. Michigan Ave., Suite 700, Chicago, IL 60611; e-mail: [email protected]. 0363-5023/15/4003-0033$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.12.007
factor can stimulate the formation of mature and mechanically competent bone, although the best combinations of these signaling proteins and the ideal carrier substances for timely release remain under investigation.8 Autologous bone grafting within induced granulation tissue membranes, otherwise known as the Masquelet technique, is a relatively simple method of treating segmental bone defects in the upper and lower extremities.9e20 The technique is applicable to both aseptic and septic conditions leading to substantial bone loss and requires no advanced skills in microvascular surgery. In the first stage, a thorough debridement is performed, the segmental bone defect is bridged by a tubularized construct of methylmethacrylate, and the bone is stabilized by orthopedic hardware. A thin fibrous membrane forms around the cement spacer within 4 weeks. In a second operation, the cement spacer is removed while preserving the membrane and the contained void is filled with cancellous autograft. This grafting method is capable of addressing segmental bone defects in the limbs measuring several centimeters in length with reported union rates of 82% to 100%.11 The majority of publications in the English and French literature pertain to use of the Masquelet technique in the treatment of segmental bone defects in the lower extremities. There are few full reports of managing bone defects in the upper extremities,10,11,13,20 supporting our observation that this approach has not become widely used by hand surgeons. We describe the basic principles of this technique and present a case example in which an infected radial shaft fracture was effectively treated. The patient consented to have data concerning her case submitted for publication.
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
593
Surgical Technique
A relatively simple technique to address large segmental bone defects in the upper extremity is described, along with a case example. (J Hand Surg Am. 2015;40(3):593e598. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Induced membrane, Masquelet technique, bone grafting, segmental bone defect, osteomyelitis.
594
INDUCED-MEMBRANE BONE GRAFTING
Surgical Technique FIGURE 1: A Posteroanterior and B lateral radiographs of the left forearm 6 weeks after injury and repair showing loosening of both fracture fixation implants and resorption of bone in the radial shaft.
INDICATIONS AND CONTRAINDICATIONS The Masquelet technique can be utilized in the treatment of epiphyseal, metaphyseal, or diaphyseal bone loss secondary to tumor, trauma, or infection with segmental defects measuring up to 25 cm in length.13 The technique can also be performed in conjunction with management of soft tissue deficiencies. Poor patient compliance is an absolute contraindication to the operation. Relative contraindications include massive tissue necrosis, radiation, chronic systemic steroid use, smoking, and malnutrition, all of which which may inhibit bone healing.
more than one surgical debridement and temporary stabilization of the osseous defect may be indicated before definitive fixation and insertion of a cement spacer. Impregnating methylmethacrylate with a powdered antibiotic targeted at a known or suspected pathogen may assist in sterilization of the wound. The use of a cement spacer in this fashion has been previously described and is analogous to the application of antibiotic beads in the treatment of osteomyelitis.10,11,19 After 4 weeks, the resultant thin fibrous membrane is incised and the cement spacer is removed en bloc or piecemeal. The rigidity of the orthopedic fixation construct is assessed and carefully augmented or revised in the event of loosening. The induced membrane is made of a type 1 collagen-heavy matrix with fibroblastic cells and contains high concentrations of growth and osteogenic factors.11,15,17 The contained void is filled with morsellized cancellous autograft, an abundant amount of which can be obtained from the iliac crest or femoral canal, and the slit in the membrane is closed.5,16 Cancellous allograft and demineralized bone matrix can be added as
SURGICAL TECHNIQUE In the first stage, the wound is thoroughly debrided of devitalized tissue, the bone ends are freshened to bleeding tissue, and the intramedullary canals are drilled for a limited distance to promote increased vascularity. The bone is then stabilized, preferably with a plate and screws, and the void is filled with a tubularized construct of methylmethacrylate. In the event of a grossly contaminated or infected wound, or both, J Hand Surg Am.
r
Vol. 40, March 2015
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Surgical Technique
INDUCED-MEMBRANE BONE GRAFTING
FIGURE 2: A Intra-operative picture of the left radius immediately after debridement of necrotic bone, revision plate fixation, and insertion of an antibiotic-impregnated cement spacer. B Posteroanterior radiograph of the left forearm showing the revision construct.
FIGURE 3: A Intra-operative picture of the induced fibrous membrane after removal of the cement spacer and before insertion of the bone graft. B Posteroanterior and C lateral radiographs of the left forearm showing well-contained bone graft.
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extenders, if the volume of cancellous autograft is insufficient. The membrane protects against autograft bone resorption and soft-tissue interposition and serves as a barrier to outward diffusion of growth and osteoinductive factors during the course of bone healing.11,12 The eventual shape of the healed bone graft will be defined by the dimensions of the membrane.
Surgical Technique
POSTOPERATIVE MANAGEMENT The extremity is protected by restricting load bearing, and a splint may be utilized at the discretion of the treating surgeon. Application of an external bonegrowth stimulator can be considered, although there are no reports validating the benefit of this technology in combination with the Masquelet technique. Serial radiographs and clinical examination are effective means of assessing bone healing. Computerized tomography examination of the graft site is our preferred method of confirming graft consolidation. PEARLS, PITFALLS, AND COMPLICATIONS Some authors have recommended molding the cement spacer over the bone ends in order to ensure continuity of the induced membrane.11,17 Temporarily removing the spacer during the final stage of cement polymerization may prevent heat damage to the bone and surrounding soft tissue. Securing the spacer to the overlying plate with a screw will inhibit migration. Two recent studies have suggested an optimal time of 4 weeks for bone grafting into the induced membrane. In a random sample of 14 patients undergoing the Masquelet technique, Aho et al9 found that vascularization in membranes was greatest at 1 month and decreased to less than 60% in 3-month-old samples. One-month old samples had the highest expression of vascular endothelial growth factor, interleukin-6, and type-1 collagen expression, whereas 2-month old membranes expressed less than 40% of the levels of 1-month old membranes. Markers of stemcell differentiation into the osteoblastic lineage were also greater in 1-month-old membranes in comparison with 2-month old membranes. Pelissier et al15 studied the induced-membrane technique in rabbits and found that bone morphogenetic protein-2 production peaked at 4 weeks after cement implantation and gradually declined over the ensuing month. Several authors have recognized a lag to bone bridging after grafting into an induced membrane. In a series of 35 cases described by Masquelet et al,13 the average time to full weight bearing after grafting segmental defects in the upper and lower extremities J Hand Surg Am.
FIGURE 4: Computerized tomography image of the left forearm 8 months after bone grafting of the radial shaft defect showing a small triangular lucency in the midregion of the graft.
was 8.5 months (range, 6e17 mo). Delays to graft consolidation in other studies have ranged from 3 to 18 months.11 Consequently, this technique may not be appropriate in cases where a potentially more rapid restorative approach is desired, such as a vascularized bone transfer.2,3 Packing a large mass of graft too tightly may potentially impede revascularization, and a graft composition containing more than 25% of a volume extender may conceivably slow bone healing.11,17 The occasional need for repeat bone grafting to address a delayed or nonunion has been reported.19 Other potential problems with the Masquelet technique include loosening of the fixation implant, infection, fracture through the graft, and bone resorption. A fracture through the graft may occur before the complete corticalization of bone, a process that can take more than one year. This risk of fracture is potentially greater with use of external fixation in comparison with intramedullary nails or plate-andscrew constructs.17 Graft resorption was recently reported in 3 children who underwent induced-membrane reconstruction after excision of malignant bone tumors from the r
Vol. 40, March 2015
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Surgical Technique
INDUCED-MEMBRANE BONE GRAFTING
FIGURE 5: A Lateral radiograph and B computed tomography image of the left forearm one year after repeat bone grafting showing consolidation of the graft.
plate fixation of both diaphyseal fractures (Fig. 2A,B). There was no gross purulence. The cement spacer was removed after a 4.5-week course of intravenous antibiotic treatment directed at a polymicrobial infection, and a cylindrical fibrous membrane spanning the bone defect was filled with a mixture of autogenous cancellous bone from the contralateral iliac crest, allograft bone chips, and demineralized bone matrix (Fig. 3AeC). Intravenous antibiotic treatment was continued for an additional 1.5 weeks, and the repeat intraoperative cultures showed no organismal growth. The ulna healed within 8 weeks, whereas an asymptomatic atrophic nonunion in the midregion of the radial bone graft was discerned by computerized tomography imaging 9 months later (Fig. 4), despite rigid splinting and application of a pulsed electromagnetic field bone growth stimulator device (Biomet EBI Bone Healing System, Parsippany, NJ). The defect was treated by insertion of additional autogenous cancellous bone harvested from the ipsilateral olecranon process, splinting, and continued application of the bone healing stimulator. Intraoperative cultures were again negative. A repeat computed tomography scan 6 months later showed progressive but incomplete bone healing. Another computed
femur.21 The authors acknowledged that some of the recommendations made by the developers of the Masquelet technique were not followed. Hypotheses put forward to explain bone resorption included a 6to 7-month delay between insertion of the cement spacer and bone grafting, suboptimal implant stability, the considerable size of each reconstructed defect, the use of excessive allograft in comparison to autograft, and possible tumor recurrence or infection. CASE EXAMPLE An 18-year-old track athlete sustained an open left diaphyseal both-bone forearm fracture in a pole vaulting event that was initially treated by emergent wound debridement and plate fixation. She presented for a second opinion 6 weeks later with persistent forearm pain and swelling. Imaging studies revealed failure of implant fixation and suspected osteomyelitis of the radial shaft with segmental bone loss (Fig. 1A,B). A 2-stage reconstruction technique was undertaken with the first stage involving debridement of necrotic and infected bone, implantation of an antibiotic-impregnated (tobramycin and vancomycin) cement spacer to span a 4.5-cm segmental defect in the radial shaft, and revision J Hand Surg Am.
r
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INDUCED-MEMBRANE BONE GRAFTING
Surgical Technique
tomography scan one year after repeat bone grafting (22 mo after the first stage of the Masquelet technique) showed bone consolidation (Fig. 5A,B). The patient was able to return to competitive hurdling one year after the initial debridement procedure and pole vaulting after confirmation of graft consolidation. The induced membrane technique is an effective tool to address large segmental bone defects in the upper extremity. The method is particularly useful in cases of concomitant bone loss and infection and does not require the treating surgeon to be skilled in microvascular techniques. The membrane delivers growth and osteoinductive factors and promotes the revascularization and maturation of cancellous bone. Studies support an optimal time period of 4 weeks between insertion of the cement spacer and exchange of the cement spacer for bone graft. A delay in graft consolidation from several months to more than one year is expected and should be considered when deciding upon the appropriateness of this technique for each patient under consideration.
7.
8.
9.
10.
11.
12.
13.
14.
15.
ACKNOWLEDGMENTS The authors would like to thank Dr. Thomas A. Wiedrich for assisting in the care of the patient presented.
16.
REFERENCES
17.
1. DeCoster TA, Gehlert RJ, Mikola EA, Pirela-Cruz MA. Management of posttraumatic segmental bone defects. J Am Acad Orthop Surg. 2004;12(1):28e38. 2. Gan AWT, Puhaindran ME, Pho RWH. The reconstruction of large bone defects in the upper limb. Injury. 2013;44(3):313e317. 3. Gaskill TR, Urbaniak JR, Aldridge JM III. Free vascularized fibular transfer for femoral head osteonecrosis: donor site and graft site morbidity. J Bone Joint Surg Am. 2009;91(8):1861e1867. 4. Khan SN, Cammisa FP, Harvinder SS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad Orthop Surg. 2005;13(1):77e86. 5. Myeroff C, Archdeacon M. Autogenous bone graft: donor sites and techniques. J Bone Joint Surg Am. 2011;93(23):2227e2236. 6. Rigal S, Merloz P, Le Nen D, Mathevon H, Masquelet AC, the French Society of Orthopaedic Surgery and Traumatology (SoFCOT).
J Hand Surg Am.
18.
19.
20.
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Vol. 40, March 2015
![[Masquelet technique for the treatment of large dia- and metaphyseal bone defects].](/assets/img/hold.png)
