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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 54  |  Issue : 1  |  Page : 67-71

Staged bone grafting using the induced membrane technique in the management of infected nonunion of long bones


Department of Orthopedic, Faculty of Medicine, Suez Canal University, Ismailia Governorate, Egypt

Date of Submission01-Apr-2019
Date of Acceptance22-Apr-2019
Date of Web Publication24-Sep-2019

Correspondence Address:
MD, PhD Mohamed Nabil
Faculty of Medicine, Suez Canal University, Ismailia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eoj.eoj_4_19

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  Abstract 

Introduction The treatment of bone defect is a demanding matter especially in the presence of infected nonunion. The technique of bone grafting within induced membranes offers a feasible option with nominal complications.
Patients and methods In the time period from September 2010 until October 2012, patients who came to the orthopedic emergency in Suez Canal University Hospitals with posttraumatic bone defects and infected nonunion were involved in the study. We used the induced membrane technique and Ilizarov external fixation in all included patients.
Results A total of 11 consecutive patients were identified within the time period. The length of bone defect ranged from 2 to 7 cm. All patients demonstrated radiographic evidence of union over the defect after treatment with a mean duration of 88.4 days (84–96 days) from the bone grafting surgery till the appearance of radiographic consolidation. No complication was encountered in this series.
Conclusion Masquelet technique is effective in the treatment of cases of infected nonunion of long bones.

Keywords: induced membrane technique, infected nonunion, segmental bone loss


How to cite this article:
Nabil M. Staged bone grafting using the induced membrane technique in the management of infected nonunion of long bones. Egypt Orthop J 2019;54:67-71

How to cite this URL:
Nabil M. Staged bone grafting using the induced membrane technique in the management of infected nonunion of long bones. Egypt Orthop J [serial online] 2019 [cited 2019 Nov 12];54:67-71. Available from: http://www.eoj.eg.net/text.asp?2019/54/1/67/267738


  Introduction Top


Wide-ranging bone defect of limbs is a gigantic difficulty faced by orthopedic surgeons and reconstruction is always mandatory for acceptable anatomical and functional outcomes [1]. It may occur after a diversity of causes such as bone infections, trauma, congenital defects, or extensive excision of malignant tumors. In the past, the complexity in dealing with segmental long bone defects usually ended with amputations [2].

The treatment of bone defect is a demanding matter especially in the presence of infected nonunion. Small defects could be managed with nonvascularized cancellous bone grafts, which have critical limits of maximum 6.0–7.0 cm length [2],[3]. Limb saving surgery has progressed over the last 50 years. During World War II, substantial cancellous bone autograft has been the basis of management [4],[5]. Nonvascularized grafts could not be well thought-out as a dependable choice for larger bone defects. Vascularized bone grafts, bone transport, allografts, and fibular protibia grafting are other accessible choices for treatment. Vascularized bone grafting has its own difficulty and demands microvascular surgical skills [6]. The French technique of bone grafting within induced membranes, or else known as the Masquelet technique, offers a feasible option with nominal complications [7],[8].


  Patients and methods Top


In the time period from September 2010 until October 2012, patients who came to the orthopedic emergency in Suez Canal University Hospitals with posttraumatic bone defects and infected nonunion were involved in the study. The study was approved by the institutional ethics committee in the Orthopedic department, Faculty of medicine, Suez Canal University, Ismailia, Egypt. A precise evaluation of every patient was done for the type of trauma, site, and condition of soft tissue. The method of bone fixation and occurrence of infection were registered. A formal consent was obtained from every patient to do this technique.

A total of 11 consecutive patients were identified within the time period. The series included nine males and two females, having a mean age of 37 years (22–53 years). The bone defects were located at the tibia (six cases) and the femur (five cases). Six cases had closed fractures of the midshaft of the tibia fixed with interlocking nail but complicated with infected nonunion, while the remaining five cases had open fractures of the shaft of the femur with segmental bone defect (Gustilo Type IIIA) treated with Ilizarov external fixation and also complicated with infected nonunion.

Surgical technique

The limb was draped in the ordinary method. Careful debridement, washing, and dissection were done as well exposing the fracture site and the fracture ends were cut and freshened. The length, alignment, and rotation of the injured limb were restored. Ilizarov external fixator was used as the standard method of fixation in all cases ([Figure 1]). After fixation had been accomplished, the segmental bone defect was dealt with. The defective segment was measured and filled with polymethylmethacrylate cement spacer. The length of bone defect ranged from 2 to 7 cm with a mean of 5.08 cm. A measure of 2 g of vancomycin was added to 40 g of cement and mixed together ([Figure 2]). Then closure was done in layers in the usual manner. The mean duration elapsed between the surgery of Ilizarov external fixation with application of cement spacer and second surgery of bone grafting (duration of cementation) was 43.72 days (35–56 days). In the second stage surgery, we used the fibular bone graft in two cases and the cancellous bone harvested from the iliac crest together with bone granules in nine cases. Cancellous bone graft was mixed with the bone graft substitute with a variable amount according to the size of defect. Incision was done on the previous one and dissection until reaching the defect. The biomembrane was opened. Then, the cement spacer was extracted. Then, the biomembrane was irrigated to get rid of any residual debris. Then, a mixture of cancellous bone graft and artificial bone granules was put into the defect so as to fill it ([Figure 3]). Then, the biomembrane was sutured tightly with no. 1 Vicryl and then continue closure in layers in the usual manner.
Figure 1 Infected nonunion with segmental bone loss of 5 cm at the distal third of the femur fixed with Ilizarov external fixator.

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Figure 2 Insertion of cement spacer mixed with 2 g of vancomycin inside the defect.

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Figure 3 Insertion of fibular bone graft together with corticocancellous graft harvested from the iliac crest and artificial bone granules after removal of the cement spacer.

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  Results Top


All affected limbs were fixed with Ilizarov external fixation. All patients demonstrated radiographic evidence of union over the defect after treatment with a mean duration of 124 days (98–152 days) from the bone grafting surgery till the appearance of radiographic consolidation ([Figure 4]). Full weight bearing was achieved in all cases after a time range from 8 to 12 months with a mean of 9.45 months. At the final follow-up, seven patients were walking normally while four patients used a cane during walking.
Figure 4 Removal of Ilizarov and application of walking high above the knee cast with signs of consolidation at the graft site.

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Complications

Two cases had malalignment in the form of varus deformity at the final follow-up after 2 years. Leg length discrepancy ranged from 2 to 14 mm with a mean of 7.18 mm at the final follow-up ([Table 1]).
Table 1 Variables measured during the study

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  Discussion Top


Management of infected nonunion with segmental bone loss is still a challenging issue in orthopedic surgery. Masquelet et al. [9] described a technique taking the advantage of the biomembranes and cancellous bone autografts. Cancellous bone grafting of the defects is often postponed after initial fixation to lower the potential of infection, allow soft tissue healing, and to prevent graft resorption [10]. In open fractures, cement beads or spacers containing antibiotic are usually used for local antibiotic infiltration to the soft tissue. As well, the benefits of using such a spacer include obtaining a distinct empty space to permit later placement of cancellous bone graft, giving mechanical support, and enhancing the creation of a biomembrane.

It was suggested that the new biomembrane keeps the graft from resorption and improves blood supply and cortical bone formation. It was also suggested that after the primary application of the spacer containing antibiotic, a duration of 4–5 weeks interval is necessary for the formation and maturation of a biomembrane that is appropriate for grafting. The cement spacer also keeps the space and prevents fibrous tissue ingrowth [11]. Recent studies have shown that this biological membrane could be 0.5–1 mm thick [12] and it was suggested as being both hypervascular and watertight [8]. The function of induced biomembrane in bone healing was studied by many authors [13]. They suggested that the 4-week-old membrane has increased osteogenic function compared with the 8-week-old membrane; they concluded that the most favorable time for doing bone grafting surgery may be within 4 weeks after application of cement spacer [13]. In the current study, the mean time interval between the stage of cement spacer placement and the stage of bone graft placement is 43.72 days, which is comparable to other studies. Pelissier et al. [8] suggested that the induced membranes secrete vascular and osteoinductive growth factors and could encourage bone regeneration. Apard et al. [14] had a series of 12 patients who had 6 cm segmental bone loss in the tibia, all of whom were primarily fixed with an intramedullary nail. They reported healing following the bone grafting procedure in 11 out of 12 patients at an average of 16 weeks [14]. No study has concluded the most advantageous method of fixation for such a technique; fairly each fracture is fixed according to the treating surgeon’s preference. In this series, Ilizarov external fixator was used as the sole method of fixation for all cases. A probable effect of a fixation that is very rigid may be stress shielding close to the implant, which decreases incorporation of the bone graft at that area. This may not prohibit bony union but may add to the time that is required for osseous consolidation and influence the radiographic picture of the defect. The procedure as described by Masquelet and Begue [11] suggested putting cancellous bone autograft taken from the iliac crest inside the biomembrane lining the defect. If the amount is not enough, demineralized allograft is further mixed to the autograft in a ratio of 1 : 3 [5].

In the current study, autograft is taken mainly from the iliac crest, and fibular graft (used in two cases) with added artificial bone granules when needed was used. Biau et al. [15] harvested iliac crest corticocancellous autograft together with a medial tibial cortical autograft to fill the defect.


  Conclusion Top


In this series, Masquelet technique was used to treat posttraumatic infected nonunion successfully. Further studies will hopefully explain the grafting components required to obtain excellent healing in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hertel L, Gerber A, Schlegel U, Cordey J, Rüegsegger P, Rahn BA. Cancellous bone graft for skeletal reconstruction muscular versus periosteal bed. Preliminary results. Injury 1994; 25 (Suppl. 1):59–70.  Back to cited text no. 1
    
2.
Gerber A, Gogolewski A. Reconstruction of large segmental defects in the sheep tibia using polylactide membrane.A clinical and radiographic report. Injury 2002; 33:43–57.  Back to cited text no. 2
    
3.
Ip WY. Polylactide membranes and sponges in the treatment of segmental defects in rabbit radii. Injury 2002; 33:66–70.  Back to cited text no. 3
    
4.
Watson JT, Anders M, Moed BR. Management strategies for bone loss in tibial shaft fractures. Clin Orthop Relat Res 1995; 315:138–152.  Back to cited text no. 4
    
5.
Weinberg H, Roth VG, Robin GC, Floman Y. Early fibular bypass procedures (tibiofibular synostosis) for massive bone loss in war injuries. J Trauma 1979; 19:177–181.  Back to cited text no. 5
    
6.
Romana MC, Masquelet AC. Vascularized periosteum associated with cancellous bone graft: an experimental study. Plast Reconstr Surg 1990; 85:587–592.  Back to cited text no. 6
    
7.
Pelissier Ph, Masquelet AC, Lepreux S, Martin D, Baudet J. Behavior of cancellous bone graft placed in induced membranes. Br J Plast Surg 2002; 55:596–598.  Back to cited text no. 7
    
8.
Pelissier Ph, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res 2004; 22:73–79.  Back to cited text no. 8
    
9.
Masquelet AC, Fitoussi F, Begue T, Muller GP. Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet 2000; 45:346–353.  Back to cited text no. 9
    
10.
McCall TA, Brokaw DS, Jelen BA. Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series. Orthop Clin N Am 2010; 41:63–73.  Back to cited text no. 10
    
11.
Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin N Am 2010; 41:27–37.  Back to cited text no. 11
    
12.
Woon CY-L, Chong K-W, Wong M-K. Induced membranes − a staged technique of bone-grafting for segmental bone loss.A report of two cases and a literature review. J Bone Joint Surg Am 2010; 92:196–201.  Back to cited text no. 12
    
13.
Aho OM, Lehenkari P, Ristiniemi J, Lehtonen S, Risteli J, Leskela HV. The mechanism of action of induced membranes in bone repair. J Bone Joint Surg Am 2013; 95:597–604.  Back to cited text no. 13
    
14.
Apard T, Bigorre N, Cronier P, Duteille F, Bizot P, Massin P. Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing. Orthop Traumatol Surg Res 2010; 96:549–553.  Back to cited text no. 14
    
15.
Biau DJ, Pannier S, Masquelet AC, Glorion C. Case report: reconstruction of a 16-cmdiaphyseal defect after Ewing’s resection in a child. Clin Orthop Relat Res 2009; 467:572–577.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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Abstract
Introduction
Patients and methods
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