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Son WS, Lim EJ, Kim BS, Choi W, Cho JW, Oh JK. Consolidation of the Anteromedial Aspect of the Tibia Is Inferior to the Other Areas in the Reconstruction of Critical-Sized Bone Defect of the Tibial Shaft Using the Induced Membrane Technique: An Analysis of 111 Serial Computed Tomography of 37 Patients. J Orthop Trauma 2025; 39:46-56. [PMID: 39787507 DOI: 10.1097/bot.0000000000002928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2024] [Indexed: 01/12/2025]
Abstract
OBJECTIVES To compare the consolidation quality between the anteromedial aspect of regenerated bone (AMRB) and the other areas of regenerated bone (TORB) following the induced membrane technique (IMT) for managing critical-sized tibial shaft bone defects, and determine the factors affecting consolidation quality in the AMRB. METHODS DESIGN Retrospective comparative study. SETTING Academic Level I trauma center. PATIENTS SELECTION CRITERIA Included were patients who underwent IMT with only an intramedullary nail for tibial shaft segmental defects and serial computed tomography immediately, 6 months, and 1 year postoperatively. OUTCOME MEASURES AND COMPARISONS Comparison were made of regenerative bone volume, density, and corticalization between AMRB and TORB. RESULTS This study enrolled 37 patients with a mean age of 47.7 years (range 20-79). Twenty-eight (75.7%) patients were men. Postoperatively, the AMRB exhibited significantly more negative volumetric change than TORB at 0-1 year (-20.01% ± 25.59% vs. -13.32% ± 22.48%, P = 0.028), less positive density change 0-6 months (+197.84 ± 107.95 vs. +290.14 ± 131.74 Hounsfield unit (HU), P < 0.001) and 0-1 year (+377.51 ± 150.71 HU vs. +455.48 ± 135.04 HU, P < 0.001), and lower corticalization rate in 1 year (49.77% ± 29.42% vs. 82.27 ± 19.73%, P < 0.001). Significant factors included fracture-related infection (FRI) ( P = 0.047 and P = 0.048 at 0-6 months and 0-1 year, respectively) and longer defect length ( P = 0.032 and P = 0.020) for the negative volumetric AMRB changes; older age ( P = 0.004 and P = 0.016) for the AMRB negative density changes; higher percentage of mixed recombinant human bone morphogenetic protein-2 in graft material ( P = 0.013 in 0-6 months) for the AMRB positive density change; FRI ( P = 0.024) for the inferior corticalization rate of the AMRB; FRI ( P = 0.026 in 0-1 year), longer defect length ( P = 0.017 in 0-6 months), and higher mixed demineralized bone matrix percentage ( P = 0.010 in 0-1 year) for the difference in density change between the AMRB and TORB; higher mixed demineralized bone matrix percentage ( P = 0.023) for the difference between the AMRB and TORB in corticalization rates. CONCLUSIONS The tibial shaft's anteromedial aspects demonstrated significantly inferior consolidation after IMT, especially in terms of volume at 6 months, density at 6 months and 1 year, and corticalization at 1 year postoperatively. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Whee Sung Son
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea ; and
| | - Wonseok Choi
- Department of Orthopaedic Surgery, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Jae-Woo Cho
- Department of Orthopaedic Surgery, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
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Wang X, Jia C, Wu H, Luo F, Hou T, Li G, Lin S, Xie Z. Activated allograft combined with induced menbrane technique for the reconstruction of infected segmental bone defects. Sci Rep 2024; 14:12587. [PMID: 38821992 PMCID: PMC11143316 DOI: 10.1038/s41598-024-63202-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024] Open
Abstract
This study was desinged to evaluate the efficacy and safety of activated allograft combined with the induced membrane technique for reconstruction of infected segment bone defects of lower limbs. A retrospective analysis was conducted on 19 patients from May 2015 to February 2017. After debridements, the bone defects were filled with antibiotic bone cement to form the induced membrane. Autologous mesenchymal stem cells were seeded onto allografts to construct activated allograft, which was implanted into the induced membrane after infection was controlled. The clinical efficacy and complications were observed. 19 patients with 20 infected segment bone defect were evaluated. The average deficit size was 11.08 (4-17) cm in length. After a mean follow-up of 71.84 (61-82) months, bone union was achieved in 16 patients (17 sites), resulting in a final union rate of 84.21% (16/19 patients). The average bone union time was 10.18 (5-28) months. There were 2 patients with recurrence of infection, 3 patients with graft absorption, and 1 patient with malunion due to implant breakage. There were no graft-related complications. This study provides clinical significance for the treatment of patients with insufficient autologous bone.
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Affiliation(s)
- Xiaohua Wang
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Chao Jia
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Hongri Wu
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
- Department of Orthopaedics, Navy 905 Hospital, Navy Medical University, Shanghai, People's Republic of China
| | - Fei Luo
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Tianyong Hou
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Gang Li
- Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China
| | - Sien Lin
- Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China.
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, People's Republic of China.
| | - Zhao Xie
- Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China.
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Wang Z, Zou C, Zhan X, Li X, Ghen G, Gao J. Application of double plate fixation combined with Masquelet technique for large segmental bone defects of distal tibia: a retrospective study and literature review. BMC Surg 2024; 24:103. [PMID: 38600472 PMCID: PMC11007926 DOI: 10.1186/s12893-024-02396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND There is no effective consensus on the choice of internal fixation method for the Masquelet technique in the treatment of large segmental bone defects of the distal tibia. Thus, the study aimed to investigate the outcomes of the Masquelet technique combined with double plate fixation in the treatment of large segmental bone defects. METHODS This was a retrospective study involving 21 patients with large segmental bone defects of the distal tibia who were treated between June 2017 and June 2020. The length of bone defect ranged from 6.0 cm to 11 cm (mean, 8.19 cm). In the first stage of treatment, following complete debridement, a cement spacer was placed to induce membrane formation. In the second stage, double plate fixation and autologous cancellous bone grafting were employed for bone reconstruction. Each patient's full weight-bearing time, bone healing time, and Iowa ankle score were recorded, and the occurrence of any complications was noted. RESULTS All patients were followed up for 16 to 26 months (mean, 19.48 months). The group mean full weight-bearing time and bone healing time after bone grafting were 2.41 (± 0.37) months and 6.29 (± 0.66) months, respectively. During the treatment, one patient had a wound infection on the medial side of the leg, so the medial plate was removed. The wound completely healed after debridement without any recurrence. After extraction of iliac bone for grafting, one patient had a severe iliac bone defect, which was managed by filling the gap with a cement spacer. Most patients reported mild pain in the left bone extraction area after surgery. The postoperative Iowa ankle score range was 84-94 (P < 0.05). In this cohort, 15 cases were rated as "excellent", and 6 cases as "good" on the Iowa ankle scoring system. CONCLUSION The Masquelet technique combined with double plate fixation is a safe and effective method for the treatment of large segmental bone defects of the distal tibia.
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Affiliation(s)
- Zhaohui Wang
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Chengyou Zou
- The Eighth Affiliated Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaohuan Zhan
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Xianhui Li
- The Eighth Affiliated Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guocai Ghen
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Junqing Gao
- Affiliated Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China.
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Brown M, Cush G, Adams SB. Use of 3D-Printed Implants in Complex Foot and Ankle Reconstruction. J Orthop Trauma 2024; 38:S17-S22. [PMID: 38502599 DOI: 10.1097/bot.0000000000002763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 03/21/2024]
Abstract
SUMMARY Treatment of traumatic critical-sized bone defects remains a challenge for orthopaedic surgeons. Autograft remains the gold standard to address bone loss, but for larger defects, different strategies must be used. The use of 3D-printed implants to address lower extremity trauma and bone loss is discussed with current techniques including bone transport, Masquelet, osteomyocutaneous flaps, and massive allografts. Considerations and future directions of implant design, augmentation, and optimization of the peri-implant environment to maximize patient outcome are reviewed.
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Affiliation(s)
- Matthew Brown
- Department of Orthopaedic Surgery, Duke University, Durham, NC; and
| | - Gerard Cush
- SUN Orthopaedics of Evangelical, Lewisburg, PA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University, Durham, NC; and
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Hayashi K, Futamura K, Ogawa T, Sato R, Hasegawa M, Suzuki T, Nishida M, Tsuchida Y. Management of bone loss in acute severe open tibial fractures: a retrospective study of twenty nine cases-a treatment strategy with bone length preservation. INTERNATIONAL ORTHOPAEDICS 2023; 47:1565-1573. [PMID: 36932220 DOI: 10.1007/s00264-023-05760-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE The present study investigated the outcomes of bone loss associated with acute open tibial fractures classified as Gustilo-Anderson classification grade III B (GIIIB) using a bone length preservation strategy. METHODS Among acute GIIIB open tibial fractures, 29 limbs of 29 patients requiring bone loss treatment were included. The reconstruction methods for bone loss were selected among the Masquelet technique (MT), bone transport (BT), acute shortening followed by gradual lengthening (ASGL), and free vascularized fibula graft (FVFG). Primary outcome measures were the rate of bone union and time to bone union. RESULTS The median radiographic apparent bone gap (RABG) was 46.75 mm. Bone loss was treated with ASGL only in two patients in whom it was not possible to cover large soft tissue defects by a single free latissimus dorsi (LD) myocutaneous flap (with the serratus anterior (SA) muscle). The other 27 patients underwent soft tissue reconstruction and bone loss treatment with the preservation of bone length, including the MT for 23, BT for six, and FVFG for one. The bone union rate was 75.9%, and the median time to bone union was six months. Salvage surgeries were performed on all seven patients with nonunion; all of whom eventually achieved bony union. CONCLUSION Bone loss associated with acute GIIIB open tibial fractures were treated with "bone length preservation" if the size of the soft tissue defect was less than the size that was covered by a single LD myocutaneous flap (with the SA muscle).
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Affiliation(s)
- Kota Hayashi
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan.
| | - Kentaro Futamura
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Takashi Ogawa
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Ryo Sato
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Masayuki Hasegawa
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Takafumi Suzuki
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Masahiro Nishida
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Yoshihiko Tsuchida
- Orthopedic Trauma Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
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Demir M, Gunay MC, Adiguzel IF, Sahinturk V. Does the use of antibiotic spacer disrupt induced membrane function? Injury 2023; 54:1055-1064. [PMID: 36797116 DOI: 10.1016/j.injury.2023.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 02/18/2023]
Abstract
Treatment of large segmental bone defects has been a challenging and long process for both physicians and patients. At present, the induced membrane technique is one of the reconstruction techniques commonly utilized in treating large segmental bone defects. It consists of a two-step procedure. In the first one, after bone debridement, the defect is filled with bone cement. The aim at this stage is to support and protect the defective area with cement. A membrane is formed around the area where cement was inserted 4-6 weeks after the first surgical stage. This membrane secretes vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), as shown in the earliest studies. In the second step, the bone cement is removed, and the defect is filled with cancellous bone autograft. In the first stage, antibiotics can be added to the applied bone cement, depending on the infection. Still, the histological and micromolecular effects of the added antibiotic on the membrane are unknown.This study investigates the molecular and histological effects of antibiotics addition into bone cement on the induced membrane.In this study, conducted on 27 male New Zealand rabbits, the 2 cm long defects of a bone were created in the rabbit femurs. Three groups were formed by placing antibiotic-free, gentamicin, and vancomycin-containing cement in the defect area.These groups were followed for six weeks, and the membrane formed at the end of 6 weeks was examined histologically. As a result of this study, it found that the membrane quality markers (Von Willebrand factor (vwf), Interleukin 6-8 (IL), Transforming growth factor beta (TGF-β), Vascular endothelial growth factor (VEGF) were significantly higher in the antibiotic-free bone cement group. Our study has shown that antibiotics added to the cement have negative effects on the membrane. Based on the results we obtained, it would be a better choice to use antibiotic-free cement in aseptic nonunions. However, more data is needed to understand the effects of these changes on the cement on the membrane.
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Affiliation(s)
- Mahircan Demir
- Mahircan Demir Eskisehir Osmangazi University Department of Orthopaedics and Traumatology, Turkey.
| | - Muhammed Cuneyd Gunay
- Muhammed Cuneyd Gunay Eskisehir Osmangazi University Department of Orthopaedics and Traumatology, Turkey
| | - Ibrahim Faruk Adiguzel
- Ibrahim Faruk Adiguzel Ankara Etlik City Hospital Department of Orthopaedics and Traumatology, Turkey
| | - Varol Sahinturk
- Varol Sahinturk Eskisehir Osmangazi University Department of Histology and Embryology, Turkey
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Masquelet Technique for the Tibia: A Systematic Review and Meta-Analysis of Contemporary Outcomes. J Orthop Trauma 2023; 37:e36-e44. [PMID: 36026545 DOI: 10.1097/bot.0000000000002480] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 02/02/2023]
Abstract
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.
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Akan İ, Bacaksız T, Özpolat N, Tunçez M, Kazımoğlu C. Is immediate internal fixation safe in induced membrane technique? Jt Dis Relat Surg 2022; 34:151-157. [PMID: 36700277 PMCID: PMC9903124 DOI: 10.52312/jdrs.2023.829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/14/2022] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the treatment outcomes of patients treated with induced membrane technique (IMT) for the reconstruction of bone defects and to identify factors associated with the success and failure of the modified technique. PATIENTS AND METHODS Between January 2016 and April 2021, a total of 23 adult patients (20 males, 3 females; median age: 39.9 years; range, 20 to 69 years) who underwent bone reconstruction using the IMT for established pseudoarthrosis and acute bone loss were retrospectively analyzed. Fracture type, the size and location of bone defect, the nature of the index injury, the type of fixation, the interval between stages of the operation, and any diagnosis of infection or other complications of the patients were assessed. RESULTS The median bone union was achieved in 6.6 (range, 4 to 11) months. The median index of reconstruction was 19 (range, 10 to 30%). The main complications were recurrent infection in two cases and nonunion in one case. Massive graft resorption occurred in two cases. CONCLUSION Immediate internal fixation is a reliable and effective method in the treatment of complex bone defects. A large volume of autograft is required for the reconstruction of long defects, which presents as a limiting factor, particularly in patients undergoing previous surgical interventions.
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Affiliation(s)
- İhsan Akan
- İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, 35620 Çiğli İzmir, Türkiye.
| | - Tayfun Bacaksız
- Department of Orthopedics and Traumatology, Izmir Katip Çelebi University Faculty of Medicine, Izmir, Türkiye
| | - Naim Özpolat
- Department of Orthopedics and Traumatology, Balıklıgöl State Hospital, Şanlıurfa, Türkiye
| | - Mahmut Tunçez
- Department of Orthopedics and Traumatology, Izmir Katip Çelebi University Faculty of Medicine, Izmir, Türkiye
| | - Cemal Kazımoğlu
- Department of Orthopedics and Traumatology, Izmir Katip Çelebi University Faculty of Medicine, Izmir, Türkiye
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Lu Y, Lai C, Lai P, Yu Y. Induced Membrane Technique for the Management of Segmental Femoral Defects: A Systematic Review and Meta-Analysis of Individual Participant Data. Orthop Surg 2022; 15:28-37. [PMID: 36444955 PMCID: PMC9837298 DOI: 10.1111/os.13604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Yi Lu
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
| | - Chih‐Yang Lai
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
| | - Po‐Ju Lai
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
| | - Yi‐Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research CenterChang Gung Memorial Hospital and Chang Gung UniversityTao‐YuanTaiwan
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Paradowski PT, Sadzikowski K, Majewski P, Szczepaniec M. Multi-stage treatment for malunion and avascular necrosis of the femoral head following reverse oblique pertrochanteric fracture: A case report and literature review. Trauma Case Rep 2022; 41:100684. [PMID: 35942319 PMCID: PMC9356153 DOI: 10.1016/j.tcr.2022.100684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 11/21/2022] Open
Abstract
Femoral reverse oblique intertrochanteric fractures are successfully treated using intramedullary devices. Poor fracture reduction and the use of the inaproppriate implant can lead to implant failure and subsequent malunion or non-union. We present the case of a 21-year-old polytrauma female who, among other injuries, sustained a reverse oblique intertrochanteric fracture that was primarily operated on with the dynamic hip screw. After implant failure the patient developed malunion with bone defect and avascular necrosis of the femoral head. Successful salvage of the bone stock in the inter- and subtrochanteric region was achieved using the two-stage induced membrane technique. The uncemented total hip arthroplasty was performed to address the osteonecrosis of the femoral head.
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Affiliation(s)
- Przemyslaw T. Paradowski
- Department of Orthopaedics and Traumatology, Jan Biziel University Hospital, Ujejskiego 75, PL-85-168 Bydgoszcz, Poland
- Department of Surgical and Perioperative Sciences, Division of Orthopedics, Sunderby Research Unit, Umeå University, Sunderby Central Hospital of Norrbotten, SE-971 80 Luleå, Sweden
- Clinical Epidemiology Unit, Orthopedics, Department of Clinical Sciences Lund, Lund University, SE-221 85 Lund, Sweden
| | - Kamil Sadzikowski
- Department of Orthopaedics and Traumatology, Jan Biziel University Hospital, Ujejskiego 75, PL-85-168 Bydgoszcz, Poland
| | - Piotr Majewski
- Department of Orthopaedics and Traumatology, Jan Biziel University Hospital, Ujejskiego 75, PL-85-168 Bydgoszcz, Poland
| | - Marek Szczepaniec
- Department of Orthopaedics and Traumatology, Jan Biziel University Hospital, Ujejskiego 75, PL-85-168 Bydgoszcz, Poland
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Ugaji S, Matsubara H, Aikawa T, Tsuchiya H. Efficacy of Temporary Intentional Leg Shortening and Deformation for Treatment of Massive Bone and Soft Tissue Defects in Three Patients. Strategies Trauma Limb Reconstr 2022; 17:195-201. [PMID: 36756292 PMCID: PMC9886035 DOI: 10.5005/jp-journals-10080-1567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 08/22/2022] [Indexed: 01/01/2023] Open
Abstract
Aim This study describes the intentional deformation and shortening of a limb using external fixation (EF) in three patients with post-traumatic injury tibial defects and to assess the outcomes. Case description Three patients with infected non-unions and massive bone and soft tissue defects who were treated with temporary intentional leg shortening and deformation using a Taylor Spatial Frame (TSF) EF were retrospectively reviewed. The alignment was restored by gradual deformity correction and lengthening after a 2-week interval. No additional surgical intervention was required for soft tissue reconstruction after primary skin closure. Skin closure and good bone alignment were achieved in all patients. The functional outcomes and bone outcomes were evaluated for all cases according to the Paley criteria modified by the Association for the Study and Application of Methods of Ilizarov. All patients showed excellent bone outcomes. Two patients achieved excellent functional outcomes and one had a good outcome. The patient with a good outcome was unable to descend the stairs comfortably. Conclusion This technique is suitable for treating massive bone and soft tissue defects and should be considered as a treatment option. How to cite this article Ugaji S, Matsubara H, Aikawa T, et al. Efficacy of Temporary Intentional Leg Shortening and Deformation for Treatment of Massive Bone and Soft Tissue Defects in Three Patients. Strategies Trauma Limb Reconstr 2022;17(3):195-201.
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Affiliation(s)
- Shuhei Ugaji
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hidenori Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Takao Aikawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
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Farhan-Alanie MM, Ward J, Kelly MB, Al-Hourani K. Current Perspectives on the Management of Bone Fragments in Open Tibial Fractures: New Developments and Future Directions. Orthop Res Rev 2022; 14:275-286. [PMID: 35983563 PMCID: PMC9380731 DOI: 10.2147/orr.s340534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022] Open
Abstract
Open tibial fractures may be associated with bone loss at the time of the injury or following surgical debridement of the fracture. This article discusses the various treatment options available and the latest developments surrounding the management of free bone fragments in open tibial fractures.
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Affiliation(s)
- Muhamed M Farhan-Alanie
- Department of Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
- Correspondence: Muhamed M Farhan-Alanie, Email
| | - Jayne Ward
- Department of Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Michael B Kelly
- Department of Trauma & Orthopaedics, Southmead Hospital, Bristol, UK
| | - Khalid Al-Hourani
- Department of Trauma & Orthopaedics, Royal Infirmary of Edinburgh, UK
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13
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Induced Membrane Technique for the Treatment of Infected Forearm Nonunion: A Retrospective Study. J Hand Surg Am 2022; 47:583.e1-583.e9. [PMID: 34563414 DOI: 10.1016/j.jhsa.2021.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/31/2021] [Accepted: 06/09/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Infected forearm nonunion remains a challenge for the hand surgeon. Autologous bone grafting within an induced membrane following implantation of a cement spacer, also known as the Masquelet technique, is a procedure used for addressing segmental bone defects. This report summarized our experience using this technique to treat the infected forearm nonunion. METHODS We retrospectively reviewed a series of 32 patients treated for infected forearm nonunion by the 2-stage Masquelet technique between 2009 and 2018. There was an infected nonunion of the ulna in 28 patients and an infected nonunion of the radius in 4 patients. All patients had undergone an average of 2.7 procedures before presenting at our institution. Treatment involved a staged procedure in which an antibiotic-impregnated cement spacer was implanted into the bone defect following debridement without internal fixation. It was left in place for 4-6 weeks, during which time a membrane formed around the cement spacer. In the second stage, the induced membrane was incised, and the cement spacer was removed. The defect was then filled with cancellous autograft with the addition of internal fixation. Postoperative radiographs were taken for the evaluation of bone healing. The functional results of the affected forearm were evaluated for motion loss of elbow or wrist and rotation loss of forearm. RESULTS All nonunions healed without recurrent infection or loosening of internal fixation at the time of final follow-up. All the patients showed substantial functional improvement, with excellent results in 14 patients, satisfactory results in 13, and unsatisfactory results in 5. CONCLUSIONS The induced membrane technique is an effective solution for infected forearm nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Effect of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) with Hydroxyapatite Carrier in Induced Membrane Technique: A Retrospective Propensity Score-Matched Study. J Orthop Trauma 2022; 36:301-308. [PMID: 34732658 DOI: 10.1097/bot.0000000000002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) with hydroxyapatite (HA) carrier augmentation in managing critical-sized bone defect (CSBD) with induced membrane technique (IMT). DESIGN Retrospective comparative study. SETTING Academic level I trauma center. PATIENTS/PARTICIPANTS The study included 14 patients who underwent rhBMP-2 with HA carrier (rhBMP-2/HA) augmentation in IMT for managing CSBD (BMP group). Moreover, 14 patients who underwent IMT without rhBMP-2 augmentation were matched by propensity score analysis (non-BMP group). INTERVENTION IMT with or without rhBMP-2/HA augmentation. MAIN OUTCOME MEASUREMENT Changes in quality and quantity measurements of grafted bone to regenerated bone using serial computed tomography. RESULTS In the BMP and non-BMP groups, the changes in densities from grafted bone to regenerated bone were +379.63 Hounsfield unit and +248.55 Hounsfield unit (P = 0.034), changes in dense bone percentage were +37.52% and +23.31% (P = 0.027), corticalization rates under the plate were 79.70% and 39.30% (P = 0.007), changes in volume were -20.77% and -23.35% (P = 0.812), union rates were 85.71% and 78.57% (P = 0.622), numbers of patients requiring additional procedures were 4 and 3 (P = 0.663), and time to union were 316.3 and 585.45 days (P = 0.040), respectively. CONCLUSIONS RhBMP-2/HA augmentation increases the density of regenerated bone, enhances corticalization under the plate, and shortens the time to union while managing CSBD with IMT. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Stefanou N, Arnaoutoglou C, Papageorgiou F, Matsagkas M, Varitimidis SE, Dailiana ZH. Update in combined musculoskeletal and vascular injuries of the extremities. World J Orthop 2022; 13:411-426. [PMID: 35633747 PMCID: PMC9125001 DOI: 10.5312/wjo.v13.i5.411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 10/31/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient's medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.
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Affiliation(s)
- Nikolaos Stefanou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Christina Arnaoutoglou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Fotios Papageorgiou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Sokratis E Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Zoe H Dailiana
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
- Department of Hand, Upper Extremity and Microsurgery, IASO Thessalias, Larissa 41500, Greece
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Klifto KM, Azoury SC, Klifto CS, Mehta S, Levin LS, Kovach SJ. Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis. J Orthop Trauma 2022; 36:55-64. [PMID: 34633778 DOI: 10.1097/bot.0000000000002214] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs). DATA SOURCE The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020. STUDY SELECTION Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations. DATA EXTRACTION A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports". DATA SYNTHESIS Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2. CONCLUSIONS NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC; and
| | - Samir Mehta
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Wang F, Liu Y, Qiu X, Fei H, Liu W, Yuan K. Effect of Anti-Infective Reconstituted Bone Xenograft Combined with External Fixator on Serum CRP and PCT Levels and Prognosis of Patients with Bone Infection after Lower Extremity Long Bone Trauma. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:5979514. [PMID: 34504538 PMCID: PMC8423557 DOI: 10.1155/2021/5979514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/18/2021] [Indexed: 11/24/2022]
Abstract
Bone infection is one of the common complications of orthopedic surgery. After bone trauma occurs in the human body, the infection of Staphylococcus aureus and Gram-negative bacteria into the fracture area can lead to double infection of the soft tissue and bone tissue at the fracture site, leading to a variety of complications, mostly in the lower extremities. Bone infection easily causes bone destruction, bone nonunion, and bone defect, seriously affecting the quality of life of patients. The traditional treatment method of bone infection is to control the infection first and then repair the bone graft, but this method has a long course, poor efficacy, and high disability rate. In this study, anti-infective reconstituted bone xenograft (ARBX) combined with external fixation was used to treat patients with posttraumatic bone infections of the long bones of the lower extremities, to explore its efficacy, and to analyze its effects on serum CRP, PCT levels, and prognosis. Our results showed that ARBX combined with the external fixator had a good effect on the treatment of patients with bone infection after lower extremity long bone trauma, which could effectively enhance the repair and functional recovery of the limb bone, significantly alleviate the infection degree of patients, reduce the inflammatory response of the body, and have a good prognosis.
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Affiliation(s)
- Fei Wang
- The First People's Hospital of Nantong, The Second Affiliated Hospital of Nantong University, Teaching Hospital Affiliated to Kangda College of Nanjing Medical University, Nantong 226001, Jiangsu, China
| | - Yang Liu
- The First People's Hospital of Nantong, The Second Affiliated Hospital of Nantong University, Teaching Hospital Affiliated to Kangda College of Nanjing Medical University, Nantong 226001, Jiangsu, China
| | - Xiaofeng Qiu
- The First People's Hospital of Nantong, The Second Affiliated Hospital of Nantong University, Teaching Hospital Affiliated to Kangda College of Nanjing Medical University, Nantong 226001, Jiangsu, China
| | - Hao Fei
- The First People's Hospital of Nantong, The Second Affiliated Hospital of Nantong University, Teaching Hospital Affiliated to Kangda College of Nanjing Medical University, Nantong 226001, Jiangsu, China
| | - Wei Liu
- The First People's Hospital of Nantong, The Second Affiliated Hospital of Nantong University, Teaching Hospital Affiliated to Kangda College of Nanjing Medical University, Nantong 226001, Jiangsu, China
| | - Kun Yuan
- The First People's Hospital of Nantong, The Second Affiliated Hospital of Nantong University, Teaching Hospital Affiliated to Kangda College of Nanjing Medical University, Nantong 226001, Jiangsu, China
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18
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Fung B, Hoit G, Schemitsch E, Godbout C, Nauth A. The induced membrane technique for the management of long bone defects. Bone Joint J 2020; 102-B:1723-1734. [PMID: 33249891 DOI: 10.1302/0301-620x.102b12.bjj-2020-1125.r1] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT. METHODS A systematic search was performed in CINAHL, The Cochrane Library, Embase, Ovid MEDLINE, and PubMed. We included articles from 1 January 1980 to 30 September 2019. Studies with a minimum sample size of five cases, where the IMT was performed primarily in adult patients (≥ 18 years old), in a long bone were included. Multivariate regression models were performed on patient-level data to determine variables associated with nonunion, postoperative infection, and the need for additional procedures. RESULTS A total of 48 studies were included, with 1,386 cases treated with the IMT. Patients had a mean age of 40.7 years (4 to 88), and the mean defect size was 5.9 cm (0.5 to 26). In total, 82.3% of cases achieved union after the index second stage procedure. The mean time to union was 6.6 months (1.4 to 58.7) after the second stage. Our multivariate analysis of 450 individual patients showed that the odds of developing a nonunion were significantly increased in those with preoperative infection. Patients with tibial defects, and those with larger defects, were at significantly higher odds of developing a postoperative infection. Our analysis also demonstrated a trend towards the inclusion of antibiotics in the cement spacer having a protective effect against the need for additional procedures. CONCLUSION The IMT is an effective management strategy for complex segmental bone defects. Standardized reporting of individual patient data or larger prospective trials is required to determine the optimal implementation of this technique. This is the most comprehensive review of the IMT, and the first to compile individual patient data and use regression models to determine predictors of outcomes. Cite this article: Bone Joint J 2020;102-B(12):1723-1734.
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Affiliation(s)
- Benjamin Fung
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada.,Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Graeme Hoit
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Emil Schemitsch
- Department of Surgery, London Health Sciences Centre, London, Canada
| | - Charles Godbout
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada.,Bruyère Research Institute, Ottawa, Canada
| | - Aaron Nauth
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Orthopaedic Surgery, St. Michael's Hospital, Toronto, Canada
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19
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Andrzejowski P, Masquelet A, Giannoudis PV. Induced Membrane Technique (Masquelet) for Bone Defects in the Distal Tibia, Foot, and Ankle: Systematic Review, Case Presentations, Tips, and Techniques. Foot Ankle Clin 2020; 25:537-586. [PMID: 33543716 DOI: 10.1016/j.fcl.2020.08.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bone defects to the distal tibia, foot, and ankle can be challenging to reconstruct. The induced membrane (Masquelet) technique has become an established method of repair for challenging areas of bone loss. It has been applied in acute open fractures, chronic nonunion, osteomyelitis, and gout erosion. This article presents a systematic review of distal tibia, foot, and ankle results using the Masquelet procedure, which should be considered in cases of challenging critical bone loss. Further work is needed to present large studies of the procedure on foot and ankle patients to consolidate current knowledge.
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Affiliation(s)
- Paul Andrzejowski
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds LS1 3EX, UK
| | - Alain Masquelet
- Department of Orthopaedic Surgery, Avicenne Hospital AP-HP, 123, route de Stalingrad, Bobiny 93009, France
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds LS1 3EX, UK.
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20
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Mathieu L, Durand M, Collombet JM, de Rousiers A, de l'Escalopier N, Masquelet AC. Induced membrane technique: a critical literature analysis and proposal for a failure classification scheme. Eur J Trauma Emerg Surg 2020; 47:1373-1380. [PMID: 33226484 DOI: 10.1007/s00068-020-01540-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/31/2020] [Indexed: 02/08/2023]
Abstract
The reconstruction of long-bone segmental defects remains challenging, with the three common methods of treatment being bone transport, vascularized bone transfer, and the induced membrane technique (IMT). Because of its simplicity, replicability, and reliability, usage of IMT has spread all over the world in the last decade, with more than 300 papers published in the PubMed literature database on this subject so far. Most of the clinical studies have reported high rates of bone union, yet some also include more controversial results with frequent complications and revision surgeries. At the same time, various experimental research efforts have been designed to understand and improve the biological properties of the induced membrane. This literature review aims to provide an overview of IMT clinical results in terms of bone union and complications and to compare them with those of other reconstructive procedures. In light of our findings, we then propose an original classification scheme of IMT failures distinguishing between preventable and nonpreventable failures.
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Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Marjorie Durand
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Jean-Marc Collombet
- Military Biomedical Research Institute (IRBA), 1 place Général Valérie André, 91220, Brétigny-sur-Orge, France
| | - Arnaud de Rousiers
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Nicolas de l'Escalopier
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Alain-Charles Masquelet
- Department of Orthopedic, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
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21
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Raina DB, Matuszewski LM, Vater C, Bolte J, Isaksson H, Lidgren L, Tägil M, Zwingenberger S. A facile one-stage treatment of critical bone defects using a calcium sulfate/hydroxyapatite biomaterial providing spatiotemporal delivery of bone morphogenic protein-2 and zoledronic acid. SCIENCE ADVANCES 2020; 6:6/48/eabc1779. [PMID: 33246951 PMCID: PMC7695465 DOI: 10.1126/sciadv.abc1779] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/09/2020] [Indexed: 05/11/2023]
Abstract
Bone morphogenic proteins (BMPs) are the only true osteoinductive molecules. Despite being tremendously potent, their clinical use has been limited for reasons including supraphysiological doses, suboptimal delivery systems, and the pro-osteoclast effect of BMPs. Efforts to achieve spatially controlled bone formation using BMPs are being made. We demonstrate that a carrier consisting of a powder of calcium sulfate/hydroxyapatite (CaS/HA) mixed with bone active molecules provides an efficient drug delivery platform for critical femoral defect healing in rats. The bone-active molecules were composed of osteoinductive rhBMP-2 and the bisphosphonate, and zoledronic acid (ZA) was chosen to overcome BMP-2-induced bone resorption. It was demonstrated that delivery of rhBMP-2 was necessary for critical defect healing and restoration of mechanical properties, but codelivery of BMP-2 and ZA led to denser and stronger fracture calluses. Together, the CaS/HA biomaterial with rhBMP-2 and/or ZA can potentially be used as an off-the-shelf alternative to autograft bone.
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Affiliation(s)
- Deepak Bushan Raina
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden.
| | - Lucas-Maximilian Matuszewski
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
| | - Corina Vater
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
| | - Julia Bolte
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
| | - Hanna Isaksson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden
- Lund University, Department of Biomedical Engineering, Lund 22100, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden
| | - Magnus Tägil
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden
| | - Stefan Zwingenberger
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
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22
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Bilichtin E, de Rousiers A, Durand M, de l'Escalopier N, Collombet JM, Rigal S, Mathieu L. Bone reconstruction by the induced membrane technique. What differences between conventional and ballistic trauma? Orthop Traumatol Surg Res 2020; 106:797-801. [PMID: 32376203 DOI: 10.1016/j.otsr.2019.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/17/2019] [Accepted: 10/07/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The induced membrane technique (IMT) has been widely evaluated for reconstruction of post-traumatic bone defects. However, no specific evaluation was conducted in ballistic injuries. The objective of the present study was to compare IMT in conventional trauma (CT) versus ballistic trauma (BT) managed in a military trauma center. METHODS A retrospective study was conducted between 2009 and 2018 in patients treated by IMT for post-traumatic bone defects, whatever the defect location. Endpoints comprised bone union, residual infection, additional bone grafting and lower-limb amputation. RESULTS Thirty-six patients were included: 24 in the CT and 12 in the BT group. Demographics and injury pattern were similar in both groups, with open fracture and infected lesions predominating. The only significant difference was that tibial bone defects were larger in the BT group. Operative parameters and results were also similar. At a mean 24 months' follow-up, bone union rate was 83% in both groups, without significant differences in residual infection, complementary grafting or late amputation. CONCLUSION IMT is appropriate to bone reconstruction in the aftermath of ballistic trauma, with similar results to those obtained in conventional trauma. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Emilie Bilichtin
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'Instruction des Armées Percy, 101, avenue Henri Barbusse, 92140 Clamart, France
| | - Arnaud de Rousiers
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'Instruction des Armées Percy, 101, avenue Henri Barbusse, 92140 Clamart, France
| | - Marjorie Durand
- Institut de recherche biomédicale des armées, D19, 91220 Brétigny-sur-Orge, France
| | - Nicolas de l'Escalopier
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'Instruction des Armées Percy, 101, avenue Henri Barbusse, 92140 Clamart, France
| | - Jean-Marc Collombet
- Institut de recherche biomédicale des armées, D19, 91220 Brétigny-sur-Orge, France
| | - Sylvain Rigal
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'Instruction des Armées Percy, 101, avenue Henri Barbusse, 92140 Clamart, France; Chaire de chirurgie appliquée aux armées, École du Val-de-Grâce, 1, place Alphonse Laveran, 75005 Paris, France
| | - Laurent Mathieu
- Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'Instruction des Armées Percy, 101, avenue Henri Barbusse, 92140 Clamart, France; Chaire de chirurgie appliquée aux armées, École du Val-de-Grâce, 1, place Alphonse Laveran, 75005 Paris, France.
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Cho JW, Kent WT, Oh CW, Kim BS, Cho WT, Oh JK. Bone-Graft Resorption Reduced by the Induced Membrane Technique and Factors Affecting Volumetric Changes: An Analysis of 120 Serial Computed Tomographic Scans in 40 Patients. J Bone Joint Surg Am 2020; 102:1269-1278. [PMID: 32675677 DOI: 10.2106/jbjs.19.00804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the volumetric changes of grafted bone over time when using the induced membrane technique. This study investigates the volumetric changes of bone graft using serial computed tomographic (CT) scans following the induced membrane technique. METHODS Patients with critical-sized bone defects had serial CT scans after undergoing bone-grafting using the induced membrane technique. CT scans to evaluate the volume of bone graft were obtained immediately postoperatively and at 6 and 12 months. The change in the volume of bone graft was determined at 6 and 12 months postoperatively. Patient demographic characteristics, the location and composition of the bone graft, and the type of fixation construct were analyzed. RESULTS Forty patients met inclusion criteria. There were 27 tibiae and 13 femora with a mean size defect of 8.6 cm (range, 2.5 to 20.6 cm). Of these patients, 21 received autograft with cancellous bone graft and 19 received mixed autogenous bone with demineralized bone matrix (DBM) at a mean time of 17 weeks after the membrane formation. For the first 6 months, there was an overall osseous resorption of -9.9%. The overall graft volume from 6 to 12 months demonstrated an increase of osseous volume by +1.6%. For the entire 12-month period, there was a mean graft volume resorption of -8.3%. A correlation was found between the early volumetric changes of grafted bone and the percentage of DBM in the graft mixture. A correlation was also found between the late volumetric changes and the location of defect or the type of fixation. CONCLUSIONS At 1 year after use of the induced membrane technique for the treatment of a critical-sized bone defect, resorption of the grafted bone averaged -8.3%. The volumetric changes were influenced by the property of the grafted bone, the fixation construct, and the location of the defect. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jae-Woo Cho
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - William T Kent
- Department of Orthopedic Surgery, University of California, San Diego, San Diego, California
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Won-Tae Cho
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
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Zeng GJ, Foong WS, Xu S, Pang HN. Induced Membrane Bone Grafting Technique for Treatment of Large Postinfectious Acetabular Bone Defects. Arthroplast Today 2020; 6:322-329. [PMID: 32514422 PMCID: PMC7267680 DOI: 10.1016/j.artd.2020.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Gerald Joseph Zeng
- Corresponding author. Singapore General Hospital, Outram Road, Singapore 169608, Singapore. Tel.: +6591892886.
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Hsu CA, Chen SH, Chan SY, Yu YH. The Induced Membrane Technique for the Management of Segmental Tibial Defect or Nonunion: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5893642. [PMID: 32596336 PMCID: PMC7273462 DOI: 10.1155/2020/5893642] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/07/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To identify the predicting factors for union and infection after applying the induced membrane technique (IMT) for segmental tibial defects. METHODS A systematic review was carried out following the PRISMA guidelines. All databases were searched for articles published between January 2000 and February 2018 using the keywords "Masquelet technique" and "induced membrane technique." Studies in English reporting more than 5 cases with accessible individual patient data were included. A meta-analysis was performed. Odds ratios (OR) with 95% confidence intervals were calculated. RESULTS After reviewing, 11/243 studies (115 patients) were finally selected. The mean age of the patients was 43.6 years (range: 18-84 years), and the mean length of the tibial defect was 5.5 cm (range: 0-20 cm). The multivariate logistic regression analysis revealed that the risk factors of postoperative infection after IMT were infected nonunion (p = 0.0160) and defect length ≥ 7 cm (p = 0.0291). Patients with postoperative infection after IMT had a lower union rate (p = 0.0003). Additionally, the use of an antibiotic polymethyl methacrylate cement spacer reduced the need for surgical revision (p = 0.0127). Multiple logistic regression indicated no direct association between the union rate and length of the bone defect. CONCLUSIONS IMT is a reliable and reproducible treatment for segmental tibial defects. However, initial infected nonunion and defect length greater than 7 cm are risk factors for post-IMT infection, and post-IMT infection was statistically related to nonunion.
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Affiliation(s)
- Chen-An Hsu
- Department of Orthopedic Surgery, Mackay Memorial Hosptial, 10449 Taipei, Taiwan
- Mackay Medical College, New Taipei City 252, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, 33302 Tao-Yuan, Taiwan
| | - Soa-Yu Chan
- Department of Computing and Information, Koo Foundation Sun-Yat Sen Cancer Center, Taipei, Taiwan
| | - Yi-Hsun Yu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 33302 Tao-Yuan, Taiwan
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Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020; 15:106-116. [PMID: 36466309 PMCID: PMC9679593 DOI: 10.5005/jp-journals-10080-1466] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account. MATERIALS AND METHODS We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls. CONCLUSION The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes. HOW TO CITE THIS ARTICLE Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020;15(2):106-116.
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Affiliation(s)
- Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Yashwant S Tanwar
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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27
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Wang G, Tang Y, Wu X, Yang H. Masquelet technique combined with microsurgical technique for treatment of Gustilo IIIC open distal tibial fractures: a retrospective single-center cohort study. J Int Med Res 2020; 48:300060520910024. [PMID: 32237939 PMCID: PMC7132797 DOI: 10.1177/0300060520910024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective This study was performed to investigate the clinical effects of the Masquelet technique combined with a microsurgical technique for treatment of Gustilo IIIC open distal tibial fractures. Methods Fifteen patients with a mean age of 39.3 ± 7.9 years (range, 21–43 years) with Gustilo IIIC open distal tibial fractures were treated by the Masquelet technique combined with a microsurgical technique from May 2013 to January 2017. The mean length of the bone defect was 6.9 ±2.2 cm (range, 5.2–10.7 cm). The mean area of the wound defect was 129.3 ± 41.4 cm2 (range, 83.7–180 cm2). Complications and fracture healing were recorded. At the last follow-up, the functional outcome was measured using the Iowa ankle score. Results All 15 patients achieved bone healing, and the median healing time was about 6.1 months (range, 5–8 months). No complications such as infection or nonunion occurred. At the last follow-up, the median Iowa ankle score was 82 (range, 68–88). The rate of an excellent and good Iowa ankle score was 86.6%. Conclusions Application of the Masquelet technique combined with a microsurgical technique is an effective strategy for the treatment of Gustilo IIIC open distal tibial fractures.
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Affiliation(s)
- Gang Wang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Department of Orthopaedics, the 72nd Group Army Hospital of PLA, Huzhou, Zhejiang, China
| | - Yong Tang
- Department of Orthopaedics, the 72nd Group Army Hospital of PLA, Huzhou, Zhejiang, China.,Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xuhua Wu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Huilin Yang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Nano/Micro Hierarchical Bioceramic Coatings for Bone Implant Surface Treatments. MATERIALS 2020; 13:ma13071548. [PMID: 32230848 PMCID: PMC7178122 DOI: 10.3390/ma13071548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 11/17/2022]
Abstract
Bone implants with surface modifications that promote the physiological activities of osteoblasts are the first step for osseointegration in bone repair. Hydroxyapatite is the main inorganic component in mammal bones and teeth, and nanoscaled hydroxyapatite promotes the adhesion of osteoblastic cells. In this study, we created a nano/micro hierarchical structure using micro-arc oxidation coatings and hydrothermal treatments at 150 °C, 175 °C, and 200 °C for 2, 6, 12, and 24 h. After undergoing hydrothermal treatment for 24 h, CaTiO3 began forming regular-shaped crystals at the surface at 175 °C. In order to decrease the CaTiO3 formations and increase the apatite fabrication, a shorter time of hydrothermal treatment was required at 175 °C. There was still surface damage on samples treated for 6 h at 175 °C; however, the nano/micro hierarchical structures were formed in 2 h at 175 °C. The normalized alkaline phosphatase (ALP) activities of the MC3T3-E1 cells with micro-arc oxidation (MAO) coatings and nano/micro hierarchical bioceramics coatings were 4.51 ± 0.26 and 7.36 ± 0.51 μmol p-NP/mg protein (*** P value of <0.001), respectively. The MC3T3-E1 cells with coatings showed highly statistically significant results in terms of the ALP activity. This proposed nano/micro hierarchical structure promoted cell proliferation and osteogenic differentiation of the osteoblast MC3T3-E1 cells. This study realized a promising nano system for osseointegration via bone implant surface treatments, which can promote the physiological activities of osteoblasts.
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Affiliation(s)
- Meng Mi
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | | | - Xinbao Wu
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Ayouba G, Lemonne F, Kombate NK, Bakriga B, Yaovi Edem J, André-Pierre Max U. Interest of nailing associated with the Masquelet technique in reconstruction of bone defect. J Orthop 2019; 20:228-231. [PMID: 32055148 DOI: 10.1016/j.jor.2019.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction The Masquelet technique based on induced membrane is performed in two stages, first with generally an external fixator which is more and more relayed by an internal fixator. The aim of this study is to assess the results of stabilization by using intramedullary nailing from the first stage. Patients and methods Nine patients were treated for a bone defect concerning 8 femurs and one tibia. The mean size of bone defect was 9.25 cm. It was secondary to a fracture (6 case) with bone defect and two septic and aseptic pseudarthrosis. In all cases the nailing was performed at the first stage of Masquelet. Prior to cement delivery, the site was thoroughly cleaned with iterative excisions as needed. Blood count control, normal CRP and negative culture were required before cement delivery. The cement was placed around the nail and encased the bony extremity. In the second stage, after removal of the cement, the defect was fulfilled by a mixture of cortico-cancellous autogenous graft taken from the iliac crest and phosphocalcic bone substitute. The nail was not changed in any patient. In post operative the mobilization of the above and underlying joints was immediate. Results No sepsis was detected before the second time. Early weight bearing was allowed on average at the end of the 2 nd month. Total bearing without support was allowed at a mean of 5.5 months. All patients have consolidated. One patient had a shortening of 2.35 cm. The mean follow-up was 46.1 months. The average period to effective return to work was 21 months. Conclusion The nailing performed at the first stage of the induced membrane technique (IMT) gives good results. This modification does not seem to increase the risk of infection. These good results deserve to be confirmed by other studies to confirm the interests of associating nailing to IMT from the first stage.
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Affiliation(s)
- Gamal Ayouba
- Department of orthopaedics and traumatology, Comminuty Hospital of Kegue, Lome-Togo, P.O Box 81531, Togo
| | - François Lemonne
- Department of Orthopedic and Traumatology, Hôpital de Grasse, 06130, Grasse, France
| | | | - Batarabadja Bakriga
- Department of orthopedic and traumatology, Teaching hospital of Sylvanus Olympio, Lome-Togo, P.O Box 57, Togo
| | - James Yaovi Edem
- Department of orthopedic and traumatology, Teaching hospital of Sylvanus Olympio, Lome-Togo, P.O Box 57, Togo
| | - Uzel André-Pierre Max
- Department of orthopedic and traumatology, Teaching Hospital of Pointe-à-Pitre, Guadeloupe
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Oh Y, Yoshii T, Okawa A. Ankle arthrodesis using a modified Masquelet induced membrane technique for open ankle fracture with a substantial osteochondral defect: A case report of novel surgical technique. Injury 2019; 50:2128-2135. [PMID: 31530381 DOI: 10.1016/j.injury.2019.09.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/09/2019] [Indexed: 02/02/2023]
Abstract
Reconstruction of a bone defect using the Masquelet induced membrane technique has been well described. However, there are few reports of arthrodesis using this technique. In this case report, we describe a modified Masquelet technique for ankle arthrodesis with nailing. The patient was a 32-year-old man who sustained an open fracture of the right ankle with a substantial osteochondral defect as a result of a fall. Immediately after the injury, a staged procedure using the Masquelet technique was planned. The bone defect was filled with bone cement in the acute stage, but replacement of the cement was needed 6 months after the injury because of a prolonged inflammatory reaction. Ten months after the injury, the bone cement was removed, and ankle arthrodesis was performed using an IM nail with a combination of autologous and artificial bone. As a modification of the Masquelet technique, the anterior surface of the transplant site was covered with a large but thin layer of cortical bone instead of suturing the incised membrane. At 1 year postoperatively, firm bony union was achieved and the implant was removed. At follow-up 3 years after his injury, the patient is able to walk, undertake physical work, and has no clinical signs of infection. Our experience suggests that a modified induced membrane technique may be useful when treating an open limb fracture with an extensive osteochondral defect where preservation of the joint is difficult and arthrodesis is considered.
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Affiliation(s)
- Yoto Oh
- Department of Orthopaedic and Trauma Research, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Intramedullary Nails Yield Superior Results Compared With Plate Fixation When Using the Masquelet Technique in the Femur and Tibia. J Orthop Trauma 2019; 33:547-552. [PMID: 31403558 DOI: 10.1097/bot.0000000000001579] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. DESIGN Retrospective cohort study. SETTING Four Level 1 Academic Trauma Centers. PATIENTS/PARTICIPANTS All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. INTERVENTION Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks. MAIN OUTCOME MEASUREMENTS Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. RESULTS One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN." CONCLUSIONS This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Mathieu L, Bilichtin E, Durand M, de l’Escalopier N, Murison JC, Collombet JM, Rigal S. Masquelet technique for open tibia fractures in a military setting. Eur J Trauma Emerg Surg 2019; 46:1099-1105. [DOI: 10.1007/s00068-019-01217-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/21/2019] [Indexed: 02/03/2023]
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Plate-assisted Bone Segment Transport With Motorized Lengthening Nails and Locking Plates: A Technique to Treat Femoral and Tibial Bone Defects. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e064. [PMID: 31592010 PMCID: PMC6754216 DOI: 10.5435/jaaosglobal-d-19-00064] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article describes a new bone transport technique for femoral and tibial bone defects using lengthening nails combined with locking plates. We term it plate-assisted bone segment transport (PABST).
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Raven TF, Moghaddam A, Ermisch C, Westhauser F, Heller R, Bruckner T, Schmidmaier G. Use of Masquelet technique in treatment of septic and atrophic fracture nonunion. Injury 2019; 50 Suppl 3:40-54. [PMID: 31378541 DOI: 10.1016/j.injury.2019.06.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of atrophic non-unions and large bone defects or infections remains a challenging task for the treating surgeon. In the herein study, we present our experience of the 'Masquelet technique' according to the 'diamond concept' for the treatment of complex long bone reconstruction procedures. METHODS Between February 2010 and March 2015, 150 patients (mean age 51.4) with atrophic and- /or infected non-unions were included in this prospective study. All patients received autologous bone graft, a graft expander (TCP (tricalcium phosphate)) and BMP (bone morphogenic protein). Clinical and radiological parameters were assessed at 6 weeks, and at 3, 6 and 12 months. The SF-12 questionnaire was used to evaluate the subjective health of patients. RESULTS A successful bony consolidation of the non-unions was observed in 120 (80%) cases with a median healing time of 12.1 months. The mean defect gap was 4.4cm. Initial infection was documented in 54 cases. The most frequently identified pathogen was staphylococcus epidermidis and staphylococcus aureus. A successful removal of microorganisms with subsequent healing was achieved in 39 cases (72%). The SF-12 scores of subjective physical and mental health increased from PCS 31.5 preoperatively to 36.7 one year postoperatively, while MCS increased from 45.5 to 48.7. CONCLUSIONS Our study showed that the Masquelet technique according to the 'diamond concept' is a valid method to treat complex atrophic non-unions with large bone defects and associated infection. Following the principles of the 'diamond concept' (targeted optimization of tissue engineering and bone regeneration) a high rate of success can be expected in these difficult reconstruction cases.
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Affiliation(s)
- T F Raven
- ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center for Trauma Surgery, Orthopaedics and Sports Medicine, Hospital Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany; HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany.
| | - A Moghaddam
- ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center for Trauma Surgery, Orthopaedics and Sports Medicine, Hospital Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany; HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - C Ermisch
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - F Westhauser
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - R Heller
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - T Bruckner
- Institute for Medical Biometry and Informatics, Im Neuenheimer Feld 130.3, D- 69120, Heidelberg, Germany
| | - G Schmidmaier
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
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Gindraux F, Loisel F, Bourgeois M, Oudina K, Melin M, de Billy B, Sergent P, Leclerc G, Petite H, Auber F, Obert L, Pluvy I. Induced membrane maintains its osteogenic properties even when the second stage of Masquelet's technique is performed later. Eur J Trauma Emerg Surg 2019; 46:301-312. [PMID: 31321472 DOI: 10.1007/s00068-019-01184-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE Previous clinical studies have shown the effectiveness of bone repair using two-stage surgery called the induced membrane (IM) technique. The optimal wait before the second surgery is said to be 1 month. We have been successfully performing the IM technique while waiting an average of 6 months to carry out the second stage. We hypothesised that the IM maintains its beneficial capabilities, even at a later second stage, and that there is no relation between the speed of bone union and the wait between the first and second stage. We sought to explore the biological properties of 'older' IMs sampled to substantiate our clinical observations. METHODS Thirty-four patients with a critical size defect were treated with the IM technique. In seven of these patients, pieces of the IM were collected 4.2-14.7 months after the first surgery. IM-derived cell phenotype and osteogenic potential were investigated using in vitro studies (n = 4) while IM nature and function were investigated by histology and immunohistochemistry (n = 3). RESULTS The median wait before the second surgery was 5.8 months [range 1.2-14.7] and bone healing occurred at 7.6 months [range 2.5-49.9] for 26 patients. IMs aged 4.2-14.7 months contained mesenchymal stromal cells with in vitro osteogenic potential and corresponded to a multipotent tissue with osteogenic and chondrogenic capabilities contributing to osteogenesis over time. CONCLUSION This preliminary study suggests the IM retains its powerful osteogenic properties over time and that waiting longer between the two surgeries does not delay bone union.
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Affiliation(s)
- Florelle Gindraux
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France. .,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.
| | - François Loisel
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France.,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
| | - Michael Bourgeois
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France
| | - Karim Oudina
- Laboratory of Bioengineering and Biomechanics for Bone Articulation (B2OA-UMR CNRS 7052), University Paris Diderot, Paris, France
| | | | - Benoit de Billy
- Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.,Paediatric Surgery Department, University Hospital of Besancon, Besancon, France
| | - Pauline Sergent
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France
| | - Gregoire Leclerc
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France
| | - Hervé Petite
- Laboratory of Bioengineering and Biomechanics for Bone Articulation (B2OA-UMR CNRS 7052), University Paris Diderot, Paris, France
| | - Frederic Auber
- Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France.,Paediatric Surgery Department, University Hospital of Besancon, Besancon, France
| | - Laurent Obert
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France.,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
| | - Isabelle Pluvy
- Orthopaedic and Traumatology Surgery Department, University Hospital of Besancon, Besancon, France.,Nanomedicine Lab, Imagery and Therapeutics (EA 4662), SFR FED 4234, University of Franche-Comté, Besancon, France
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37
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Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis PV. Bone Repair Using the Masquelet Technique. J Bone Joint Surg Am 2019; 101:1024-1036. [PMID: 31169581 DOI: 10.2106/jbjs.18.00842] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alain Masquelet
- Department of Orthopaedic Surgery, Avicenne Hospital, Bobiny, France
| | - Nikolaos K Kanakaris
- Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Laurent Obert
- Traumatology, Reconstructive, and Plastic Surgery Unit, CHU Jean Minjoz, Besançon, France
| | - Paul Stafford
- Orthopedic Trauma Surgery of Oklahoma, Tulsa, Oklahoma
| | - Peter V Giannoudis
- Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.,Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
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38
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In Vitro Properties for Bioceramics Composed of Silica and Titanium Oxide Composites. APPLIED SCIENCES-BASEL 2018. [DOI: 10.3390/app9010066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
It is important for oral and maxillofacial surgeons to repair craniofacial defects on oral cancer patients or patients with congenital problems. Thus, it is a challenge to develop biomaterials that promote bone regeneration as potential materials for bone repair. This work is devoted to the fabrication of bioceramics composed of silica and titanium oxide with various concentrations of titanium oxide for developing bone repair materials for dentistry and tissue engineering. The silica-based bioceramics were synthesized using the sol–gel method, and titanium oxide was added from the hydrolysis of tetrabutyl titanate. The surface morphology was observed using scanning electron microscopy. The chemical composition was measured using an energy dispersive X-ray spectrometer, and the crystal structure was identified by using an X-ray diffraction diffractometer. The pH value and ion concentrations released in simulated body fluids after immersion with bioceramic samples were measured using a pH meter and inductively coupled plasma mass spectrometry, respectively. In the cell toxicity test, the human osteosarcoma cells (MG63) were used and quantitatively assessed using an MTT assay. The results showed that the proposed bioceramics can be controlled by tuning the Si/Ti ratio to modify the dissolution rate of samples and enhance the formation of apatite. Compared to Dulbecco’s modified Eagle’s medium (DMEM) groups, the cell number of the BG_Ti75 group can be increased to 120%. Furthermore, BG_Ti75 can promote MG63 cell growth with statistical significance and keep the pH value and the released calcium ion concentrations of the soaking environment stable. The proposed bioceramics show potential for bone-regenerating capability.
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39
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Stella M, Santolini E, Autuori A, Felli L, Santolini F. Masquelet technique to treat a septic nonunion after nailing of a femoral open fracture. Injury 2018; 49 Suppl 4:S29-S33. [PMID: 30518507 DOI: 10.1016/j.injury.2018.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/06/2018] [Indexed: 02/02/2023]
Abstract
Septic nonunion is one of the most serious complications after an open fracture because both the infection and the bone defect need to be dealt with. Treatment is always protracted and expensive, and the result is uncertain. In the 1980s, Masquelet first described the technique of the induced membrane and autologous bone grafting to manage critical size bone defects. In septic nonunions, the described approach, characterised by two different surgical steps, allows a radical approach to manage the infection, and gives a significant biological stimulus to bone healing. In this case, we present a 35-year-old male patient with an open grade II femoral shaft fracture (AO / OTA 32C3). The patient was initially treated with an intramedullary nail and the resulting septic nonunion was subsequently managed with the induced membrane technique and a double-plate osteosynthesis to protect the biological chamber.
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Affiliation(s)
- Marco Stella
- Orthopaedics and Trauma Unit, Ente Ospedaliero Ospedali Galliera, Mura delle Cappuccine 14-16128, Genoa, Italy.
| | - Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10-16132, Genoa, Italy
| | - Alberto Autuori
- Orthopaedics and Trauma Unit, Ente Ospedaliero Ospedali Galliera, Mura delle Cappuccine 14-16128, Genoa, Italy
| | - Lamberto Felli
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10-16132, Genoa, Italy
| | - Federico Santolini
- Orthopaedics and Trauma Unit, Emergency Department, Ospedale Policlinico San Martino, Largo R. Benzi 10-16132, Genoa, Italy
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40
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McEwan JK, Tribe HC, Jacobs N, Hancock N, Qureshi AA, Dunlop DG, Oreffo RO. Regenerative medicine in lower limb reconstruction. Regen Med 2018; 13:477-490. [PMID: 29985779 DOI: 10.2217/rme-2018-0011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Bone is a highly specialized connective tissue and has a rare quality as one of the few tissues that can repair without a scar to regain pre-injury structure and function. Despite the excellent healing capacity of bone, tumor, infection, trauma and surgery can lead to significant bone loss requiring skeletal augmentation. Bone loss in the lower limb poses a complex clinical problem, requiring reconstructive techniques to restore form and function. In the past, amputation may have been the only option; however, there is now an array of reconstructive possibilities and cellular therapies available to salvage a limb. In this review, we will evaluate current applications of bone tissue engineering techniques in limb reconstruction and identify potential strategies for future work.
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Affiliation(s)
- Josephine K McEwan
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Howard C Tribe
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Neal Jacobs
- Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
| | - Nicholas Hancock
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir A Qureshi
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Douglas G Dunlop
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Richard Oc Oreffo
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
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41
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Ronga M, Cherubino M, Corona K, Fagetti A, Bertani B, Valdatta L, Mora R, Cherubino P. Induced membrane technique for the treatment of severe acute tibial bone loss: preliminary experience at medium-term follow-up. INTERNATIONAL ORTHOPAEDICS 2018; 43:209-215. [PMID: 30280216 DOI: 10.1007/s00264-018-4164-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Management of acute open tibial fractures with critical bone defect remains a challenge in trauma surgery. Few and heterogeneous cases have been reported about the treatment with the induced membrane technique. METHODS We prospectively evaluated three patients treated with the induced membrane technique for acute Gustilo IIIB tibial fractures with critical bone defect. Success treatment was defined by bone union with patient pain free. Clinical and radiological evaluations were performed regularly until healing, then annually and with a minimum follow-up of five years. RESULTS In all patients but one, a success was recorded, respectively, at four and six months. These two patients were pain free until the final follow-up, and no graft resorption or secondary complications related to the index surgery were observed. The third case was managed successfully with a bone transport technique. CONCLUSION The induced membrane technique is an alternative good option for the treatment of these severe lesions.
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Affiliation(s)
- Mario Ronga
- Department of Medicine and Health Sciences 'Vincenzo Tiberio', University of Molise, Via Giovanni Paolo II, 86100, Campobasso, Italy. .,Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy.
| | - Mario Cherubino
- Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Katia Corona
- Department of Medicine and Health Sciences 'Vincenzo Tiberio', University of Molise, Via Giovanni Paolo II, 86100, Campobasso, Italy
| | - Alessandro Fagetti
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Barbara Bertani
- Department of Orthopedics and Traumatology, University of Pavia, Pavia, Italy
| | - Luigi Valdatta
- Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Redento Mora
- Department of Orthopedics and Traumatology, University of Pavia, Pavia, Italy
| | - Paolo Cherubino
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
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42
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Masquelet technique for the treatment of acute osteomyelitis of the PIP joint caused by clenched-fist human bite injury: A case report. Int J Surg Case Rep 2018; 51:282-287. [PMID: 30243260 PMCID: PMC6149196 DOI: 10.1016/j.ijscr.2018.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/03/2018] [Accepted: 09/12/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The Masquelet technique is a well-known and efficient procedure for lower limb soft tissue reconstruction after severe osteomyelitis requiring bone excision. However, this technique is rarely used in the hand. PRESENTATION OF CASE The patient was 38-year-old man. We used this technique to reconstruct a proximal interphalangeal (PIP) joint osteochondral defect after osteomyelitis caused by clenched-fist human bite injury. The pathogen was Prevotella intermedia, which is an anaerobic pathogenic bacterium involved in periodontal infections and is a black-pigmented periodontal pathogen. Following completion of the Masquelet method, the bone remodeled at an angle at the PIP joint. DISCUSSION Prevotella intermedia is known as Bacteroides melaninogenicus subsp. intermedius. When the infection site is black-pigmented, this pathogen is highly suspected. The Masquelet technique is rarely used in the hand, and when used, it has been in a straight fashion in the hand. We were able to reconstruct a more anatomical, bent PIP joint, and the fixed angle of the PIP joint at 40° of flexion using Masquelet technique. CONCLUSION The angled joint resulting from this technique created a relatively normal permanently bent PIP joint.
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43
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Zhang W, Chen H, Tang P. [Recent advances in treatment of aseptic femoral shaft nonunion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:519-525. [PMID: 29806336 PMCID: PMC8430007 DOI: 10.7507/1002-1892.201712089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/30/2018] [Indexed: 11/03/2022]
Abstract
Objective To review the recent advances in treatment of aseptic femoral shaft nonunion. Methods The clinical studies about the treatments of aseptic femoral shaft nonunion in recent years were widely reviewed and analyzed. Results There are several surgical methods for aseptic femoral shaft nonunion. Due to uncertain clinical outcome, dynamization of nail should be carefully selected. The exchange nailing is suitable for the hypertrophic nonunion of the isthmal femoral shaft fracture. The exchange lateral plating is suitable for nonunion with obvious malformation. However, wave plate or dual plate should be chosen when the bone nonuinon is combined with the medial defect. The augmentation plating improves the success rate of nailing for femoral shaft nonunion, but it should be carefully selected for patients with obvious deformity or bone defect. Ilizarov technique is suitable for various bone nonunion, especially with complicated or large segmental bone defects. Induced membrane technique is also an important method for the treatment of bone nonunion with large bone defects. The clinical efficacy of the blocking screw remains to be supported by further evidence. Biological stimulants are mainly used for atrophic nonunion, and the clinical efficacy of them alone are still controversial. Conclusion Due to lack of comparative studies between different surgical methods, the orthopedist should choose the appropriate treatment according to the individual situations of the patient and the types of bone nonunion.
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Affiliation(s)
- Wei Zhang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Hua Chen
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Peifu Tang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, 100853,
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44
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Attias N, Thabet AM, Prabhakar G, Dollahite JA, Gehlert RJ, DeCoster TA. Management of extra-articular segmental defects in long bone using a titanium mesh cage as an adjunct to other methods of fixation. Bone Joint J 2018; 100-B:646-651. [DOI: 10.1302/0301-620x.100b5.bjj-2017-0817.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aims This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect. Patients and Methods A total of 17 patients (aged 17 to 61 years) treated for a segmental long bone defect by nail or plate fixation and an adjunctive TMC were included. The bone defects treated were in the tibia (nine), femur (six), radius (one), and humerus (one). The mean length of the segmental bone defect was 8.4 cm (2.2 to 13); the mean length of the titanium mesh cage was 8.3 cm (2.6 to 13). The clinical and radiological records of the patients were analyzed retrospectively. Results The mean time to follow-up was 55 months (12 to 126). Overall, 16 (94%) of the patients achieved radiological filling of their bony defect and united to the native bone ends proximally and distally, resulting in a functioning limb. Complications included device failure in two patients (12%), infection in two (12%), and wound dehiscence in one (6%). Four patients (24%) required secondary surgery, four (24%) had a residual limb-length discrepancy, and one (6%) had a residual angular limb deformity. Conclusion A titanium mesh cage is a useful adjunct in the treatment of an extra-articular segmental defect in a long bone. Cite this article: Bone Joint J 2018;100-B:646–51.
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Affiliation(s)
- N. Attias
- St. Joseph’s Hospital, 350
W Thomas Rd, Phoenix, Arizona
85013, USA
| | - A. M. Thabet
- Department of Orthopaedic Surgery and
Rehabilitation, Paul L. Foster School of Medicine,Texas Tech Health
Sciences Center, 4801 Alberta Avenue, El
Paso, Texas 79905, USA
| | - G. Prabhakar
- Paul L. Foster School of Medicine at Texas
Tech Health Sciences Center, 4801 Alberta
Avenue, El Paso, Texas
79905, USA
| | - J. A. Dollahite
- Department of Orthopaedic Surgery, University
of New Mexico, Albuquerque, New
Mexico 87131, USA
| | - R. J. Gehlert
- Department of Orthopaedic Surgery, University
of New Mexico, Albuquerque, New
Mexico 87131, USA
| | - T. A. DeCoster
- Department of Orthopaedic Surgery, University
of New Mexico, Albuquerque, New
Mexico 87131, USA
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Calcium sulfate induced versus PMMA-induced membrane in a critical-sized femoral defect in a rat model. Sci Rep 2018; 8:637. [PMID: 29330453 PMCID: PMC5766563 DOI: 10.1038/s41598-017-17430-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022] Open
Abstract
Aimed to investigate the characteristics of CS-induced membrane in comparison with the PMMA-induced membrane. Cellular components, histological changes, growth factor expressions of IL-6, VEGF, BMP-2, and TGF-β1 in the two induced membranes were compared at 2, 4, 6 and 8 weeks, respectively. We also compared the histological changes at the bone defects between CS and PMMA groups. The structural characteristics of induced membrane were similar between CS and PMMA. Endochondral ossification took place in the CS-induced membrane at 8 week. Levels of VEGF, BMP-2 and TGF-β1 in CS-induced membrane were insignificantly higher than those in PMMA-induced membrane at different time points. The expression of IL-6 was significantly higher in PMMA-induced membranes at 2nd week. In addition, osteogenic and neovascular activities of induced membranes increased with time and peaked at 6 weeks. CS promoted endochondral ossification at the broken ends of the bone defect than PMMA did. CS-induced membrane has a better capacity of generating VEGF, BMP-2 and TGF-β1.osteogenic and neovascular activities achieve highest level at 6 week. CS may have the potential to replace PMMA as a novel spacer in Masquelet technique.
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46
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Zhang Q, Zhang W, Zhang Z, Zhang L, Chen H, Hao M, Deng J, Tang P. Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation. J Orthop Surg Res 2017; 12:183. [PMID: 29178906 PMCID: PMC5702156 DOI: 10.1186/s13018-017-0684-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/09/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Currently, the common treatment for femoral nonunion with large segmental bone defect is difficult and complex. The effective surgical methods are rare, include vascularized bone grafting, Masquelet technique and Ilizarov distraction osteogenesis. The objective of this study is to investigate the outcomes of segmental femoral defects treated with monolateral external fixation using the distraction osteogenesis. METHODS We retrospectively analyzed patients with femoral nonunion with segmental bone defects (> 6 cm) between January 2010 and January 2014 in our single trauma center. All patients were treated by distraction osteogenesis with monolateral external fixation. All surgeries were performed by the same surgeon. Bone union, duration of distraction osteogenesis in days, time to consolidation in months, external fixation index (EFI), complications, and additional surgical interventions were recorded postoperatively. The modified Application of Methods of Illizarov (ASAMI) criteria were used to evaluate the operative effectiveness. RESULTS Forty-one patients were enrolled in this study for analysis. The length of the bone defect ranged from 6 to 17 cm. All patients eventually achieved healing, and no patient experienced recurrence of infection or newly developed infection. The average time needed for healing was 13 months. In terms of the incidence of complications, 3 cases axial deviations, 5 cases docking site nonunion, 23 cases pin-tract infection, 14 cases knee joint stiffness or their joint mobility declined, 2 cases osteogenesis insufficient in the distraction area,1 case refracture, and 2 cases loose external fixation pins. In terms of the evaluations of fracture healing and function, 30 patients excellent, 6 patients good, 5 patients fair, and 0 patient poor. In terms of postoperative function evaluations, 21 patients excellent, 9 patients good, 7 patients fair, and 4 patients poor. CONCLUSION For patients with femoral nonunion with large segmental bone defects, the monolateral external fixation can provide effective stability, improve compliance, and reduce complications.
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Affiliation(s)
- Qun Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Wei Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Zhuo Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Hua Chen
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Ming Hao
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Junhao Deng
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing, 100853 People’s Republic of China
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48
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Cambon-Binder A, Revol M, Hannouche D. Salvage of an osteocutaneous thermonecrosis secondary to tibial reaming by the induced membrane procedure. Clin Case Rep 2017; 5:1471-1476. [PMID: 28878907 PMCID: PMC5582313 DOI: 10.1002/ccr3.1093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 06/11/2017] [Accepted: 06/17/2017] [Indexed: 11/28/2022] Open
Abstract
Osteocutaneous thermonecrosis is a rare but devastating complication of tibial reaming, which can cause large and infected bone and cutaneous defects. The case presented here illustrates that the induced membrane technique described by Masquelet is a valuable option in treating this complication.
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Affiliation(s)
- Adeline Cambon-Binder
- Department of Orthopaedic and Hand Surgery AP-HP Hôpital Saint Antoine Université Paris 6 Pierre et Marie Curie Paris France
| | - Marc Revol
- Department of Plastic and Reconstructive Surgery AP-HP Hôpital Saint Louis Université Paris 7 Denis Diderot Paris France
| | - Didier Hannouche
- Department of Orthopaedic Surgery Hôpitaux Universitaires de Genève Université de Genève Geneva Switzerland
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49
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Luo F, Wang X, Wang S, Fu J, Xie Z. Induced membrane technique combined with two-stage internal fixation for the treatment of tibial osteomyelitis defects. Injury 2017; 48:1623-1627. [PMID: 28483358 DOI: 10.1016/j.injury.2017.04.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to observe the effects of induced membrane technique combined with two-stage internal fixation in the treatment of tibial osteomyelitis defects. METHODS A retrospective analyses for 67 cases of tibialosteomyelitis defects were admitted to our department between September 2012 to February 2015, which were treated with induced membrane technique. At the first stage, implanted with a PMMA cement spacer in the defects after radical debridement and fixed with reconstructive locked plate. Bone grafting and exchanged the plate with intramedullary nail at the second stage. RESULTS In current study, all patients were followed up for 18-35 months. Sixty-six patients achieved bone union with the average radiographic and clinical healing times of 5.55±2.19 and 7.45±1.69months, respectively. Seven patients required a second debridement before grafting, while four patients experienced a recurrence of infection or a relapse following second stage treatment. Twelve patients experienced either knee or ankle dysfunctions and 2 patients faced delayed wound healing. Donor site complications includes pain and infection were found in 7 and 3 patients, respectively with delayed stress fracture in 1 patient only. CONCLUSIONS Induced membrane technique for the treatment of tibial osteomyelitis defects, seems a reliable method. The use of reconstructive locked plate as a temporary internal fixation at the first stage and exchanged with intramedullary nail at the second stage, potentially achieves good clinical efficacy. Care should be taken to restore the joint function especially in distal tibia.
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Affiliation(s)
- Fei Luo
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing 400038, People's Republic of China.
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Sasaki G, Watanabe Y, Miyamoto W, Yasui Y, Morimoto S, Kawano H. Induced membrane technique using beta-tricalcium phosphate for reconstruction of femoral and tibial segmental bone loss due to infection: technical tips and preliminary clinical results. INTERNATIONAL ORTHOPAEDICS 2017; 42:17-24. [PMID: 28536801 DOI: 10.1007/s00264-017-3503-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to provide preliminary evidence regarding effectiveness of grafting beta-tricalcium phosphate (β-TCP) combined with a cancellous autograft for treating nonunion of long bones in the lower extremity due to infection by evaluating clinical and radiological outcomes. METHODS We retrospectively reviewed the clinical and radiological results in seven patients (six men, one woman; median age 39 years) treated by the induced membrane technique for nonunion of the femur or tibia due to infection. In the second stage of the procedure, the bony defect was filled with a combination of autologous cancellous bone and β-TCP, which were mixed in approximately the same proportions. The time interval between the second stage of the procedure and bone healing was investigated. Radiographic characteristics including maximum bone gap and radiographic apparent bone gap were evaluated. RESULTS The median follow-up period was 14 months. Bone healing was achieved in a median of six months after the second procedure. The median maximum bone gap and radiographic apparent bone gap were 55 mm and 34 mm, respectively. DISCUSSION Use of β-TCP, which has osteoconductive ability, with an autograft provided good clinical and radiological outcomes. The findings of this preliminary study suggest the potential of β-TCP as a useful bone substitute for autografts in the induced membrane technique. CONCLUSIONS Our findings suggest that β-TCP may be an effective extender when using the induced membrane technique.
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Affiliation(s)
- Gen Sasaki
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan.
| | - Yoshinobu Watanabe
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Wataru Miyamoto
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Youichi Yasui
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Shota Morimoto
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan
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