Masquelet Technique for Treatment of [601242]

ClinicalStudy
Masquelet Technique for Treatment of
Posttraumatic Bone Defects
Tak Man Wong,1,2Tak Wing Lau,1Xin Li,2Christian Fang,1
Kelvin Yeung,1,2and Frankie Leung1,2
1DepartmentofOrthopaedicsandTraumatology,TheUniversityofHongKong,QueenMaryHospital,
102,PokfulamRoad,HongKong
2ShenzhenKeyLaboratoryforInnovativeTechnologyinOrthopaedicTrauma,TheUniversityofHongKong-ShenzhenHospital,
1Haiyuan1stRoad,FutianDistrict,Shenzhen,China
CorrespondenceshouldbeaddressedtoFrankieLeung;[anonimizat]
Received21August2013;Accepted23December2013;Published6February2014
AcademicEditors:A.KhajiandR.Mascarenhas
Copyright © 2014 TakManWongetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,
whichpermitsunrestricteduse,distribution,andreproductio ninanymedium,providedtheoriginalworkisproperlycited.
Masquelettechnique,whichistheuseofatemporarycementspacerfollowedbystagedbonegrafting,isarecenttreatmentstrategy
tomanageaposttraumaticbonedefect.Thispaperdescribesaseriesof9patientstreatedwiththistechniqueofstagedbonegraftingfollowing placement of an antibiotic spacer to successfully manage osseous long bone defects. The injured limbs were stabilizedandalignedatthetimeofinitialspacerplacement.Inourseries,os seousconsolidationwassuccessfullyachievedinallcases.This
techniquegivespromisingresultinthemanagementofposttraumaticbonedefects.
1. Introduction
Segmentalbonedefectsresultingfromtraumaticinjuriesare
complicated problems with significant long-term morbidity.Historically, due to the difficulty in managing segmentallong bone defects, amputation was the preferred treatment.Limb salvage has been developed over the last half century.During World War II, massive cancellous bone autografthas been the mainstay of treatment [ 1,2]. The use of the
Ilizarovtechnique,vascularizedfibulargrafts,andacutelimbshortening have been used previously to address defectsof various lengths. Traditional bone graft techniques are
limited by uncontrollable graft resorption, even when the
recipient site is well vascularized [ 3]. More recently, the use
of an antibiotic cement spacer followed by grafting withinthis space confirmed by an induced biomembrane has beendescribed as a potential treatment strategy [ 4,5]. This paper
describes a series of patients at our institution successfullytreatedwiththistechnique.
2. Patients and Methods
Between 2009 and 2012, all patients admitted with post-traumaticbonedefectsandmanagedbyMasquelettechnique(Table 1) were recruited. The patients were evaluated for
injury type, location, soft tissue condition, length of bonedefect, antibiotic used, and duration of cementation. More-over, the type of fixation, presence of infection, and currentstateofallpatientswererecorded.
3. Surgical Technique
During the first stage, the operative extremity was prepared
and draped in the usual sterile fashion. The area of boneloss was carefully debrided and irrigated. Debris and non-
viable tissues were removed. Careful dissection was then
performed down to the fracture site and the fracture ends
were identified and debrided again. Based on preoperative
templating,thelength,alignment,androtationoftheinjuredlimb were obtained. Method of fixation depended on the
fracture type and location. For open fracture, with signifi-
cant defect, external fixator was used temporarily ( Figure1).
Onceacceptablereductionwasachieved(ensuringanatomic
length, alignment, and rotation), fixation was undertaken.
Once fixation had been achieved, attention was then turnedto the bone defect. The defect was measured and filled withapolymethylmethacrylate(PMMA)bonecementspacer.We
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2 TheScientificWorldJournal
Table1:Patientdemographics.
Patient
number/
sex/age(y)Type of
injuryFracture
typeSofttissue
conditionIndicationBonedefect,
length(cm)SpacerDefinite
fixationCurrent
StateDurationof
cementation
(days)
1/M/60Fracture
distal
humerusClosedWound
contaminatedPostoperative
wound
infection2cm GentamycinPlate
and
screwBone
graftedand
healed50
2/M/60Fracture
olecranonOpen
GustiloIIViable,
notcontaminatedBoneloss 2cm VancomycinPlate
and
screwBone
graftedand
healed57
3/M/28Fracture
distal
femurOpen
GustiloIIIAGrossinfection,
contaminatedPostoperative
wound
infection8cm GentamycinPlate
and
screwBone
graftedand
healed48
4/F/79Fractureleft
olecranonClosedInfectiondeepto
joint,
contaminatedPostoperative
wound
infection4cmGentamycin
+vancomycinPlate
and
screwBone
graftedand
healed53
5/M/53Fracture
tibial
plateauClosedDeepinfection
extendingtoknee
joint,
contaminatedPostoperative
wound
infection4cmGentamycin
+vancomycinPlate
and
screwBone
graftedand
healed48
6/M/48Fracture
oscalcisOpen
GustiloIISofttissueviable,
notcontaminatedBoneloss 2cm GentamycinPlate
and
screwBone
graftedand
healed30
7/M/61Fracture
distalfemurClosedViable,
notcontaminatedNonunion 3cmGentamycin
+vancomycinPlate
and
screwBone
graftedand
healed43
8/F/27Fracture
distal
tibiaOpen
GustiloIINotcontaminated Boneloss 2cm GentamycinPlate
and
screwBone
graftedand
healed59
9/M/60Fracture
distal
tibiaOpen
GustiloIIICMinimal
contaminatedBoneloss 4cm VancomycinPlate
and
screwBone
graftedand
healed49
(a)
(b)
Figure 1: AP (a) and lateral (b) radiographs of an open fracture right distal tibia Gustilo Type IIIA at admission. It was initially debrided,
stabilized,andshortenedwithanexternalfixator,leavingadefectoverrightdistaltibia.

TheScientificWorldJournal 3
(a)
R
(b)
Figure2:AP(a)andlateral(b)radiographsshowingfixationwithexternalfixatorandscrewsandplacementofantibioticcementspacerinto
thedefectafterthewoundhadbeenadequatelydebrided.
preferred to use 2g vancomycin or gentamicin per 40g
of cement prepared ( Figure2). The second stage of bone
grafting was performed 4–12 weeks after the first surgery.The bone graft was harvested from the iliac crest. Thefracture was approached through the previous incision andcareful dissection was performed down to the defect. Thebiomembraneencapsulatingthecementspacerwascarefullyincised.Onceexposed,thecementspacerwasremoved.Oncethe cement spacer was removed, the biomembrane capsulewas irrigated to remove any residual debris. With the defectbeing open, bone graft was placed to fill the entire defect(Figure3). The defect should be completely filled but not
overstuffed.Oncethedefectwasfilled,thebiomembranewasclosedwithabsorbablesuture.
4. Results
A total of 9 consecutive patients were identified within thetime period. The series included 7 men and 2 women, witha mean age of 53 (27–79). The bone defects were located attibia (3 cases,) the femur (2 cases), the humerus (1 case), theolecranon(2cases),andcalcaneum(1case).Fourcaseswereclosed fracture but complicated with infection or nonunion.The other five cases were open fractures with bone loss(GustiloClassificationTypeIIorIIIA).
Thelengthofbonedefectrangedfrom2cmto8cm.The
antibioticsusedforcementspacerwereeithergentamicinorvancomycin. The mean interval between the first-stage andsecond-stage surgeries was 48.5 days (30–57). All affectedlim bsw er efix edwi thscr ewa ndp la t eco n s truct.Allpa tien tsdemonstrated radiographic consolidation over the defectafter treatment ( Figure4). No complication was reported in
theseries.
5. Discussion
Treatmentoflargesegmentalbonedefectscanbechallengingfor orthopaedic surgeons. Masquelet et al. [ 6] described aprocedure combining induced membranes and cancellous
autografts.Bonegraftingofthesedefectsisoftendelayedafter
primaryfixationtoallowsofttissuehealing,decreasetheriskof infection, and prevent graft resorption [ 7]. In traumatic
wounds, antibiotic impregnated cement beads or spacers areoftenusedforlocalantibioticadministrationtothesofttissuebed. In addition, the advantages of inserting such a spacerinclude maintaining a well-defined void to allow for laterplacement of graft, providing structural support, offloadingt h ei m p l a n t ,a n di n d u c i n gt h ef o r m a t i o no fab i o m e m b r a n e .MasqueletandBegueproposedthatthismembranepreventsgraftresorptionandimprovesvascularityandcorticalization.It has been described that, after the initial placement of theantibiotic impregnated spacer, an interval of 4 to 5 weeksis needed for development and maturation of a biologicallyactivemembranethatissuitableforgrafting.Thespaceralsomaintainsthedefectandinhibitsfibrousingrowth[ 5].
Recent literature has shown that this biomembrane can
be 0.5 to 1mm thick [ 8] and has been described as both
hyper-vascular and impermeable [ 9]. Viateau et al. [ 10]
studied this technique in a sheep model and found that themembrane alone was inadequate to heal a large defect. Butwhenautologousbonegraftwasplacedwithinthemembrane,all the defects went on to heal. The technique of inducinga biomembrane at the site of an osseous defect with staged
grafting has been described in case reports for defects of
varioussizesandinvariouslocationsthroughouttheskeletalsystem. The mechanism of action of induced membranes inbone repair was studied recently by Aho and his colleagues[11]. They found that the one-month-old membrane has
higherosteogenesis-improvingcapabilitiescomparedtotwo-month-oldmembrane;theyconcludedthatoptimaltimeforperforming second-stage surgery may be within a monthafter implantation of foreign material [ 11]. In our series, the
mean interval between the first and second surgeries is 43.5days,whichiscomparabletootherstudies.
P e l i s s i e re ta l .[ 9] reported that the induced membranes
secretegrowthfactorsincludingvascularandosteoinductive

4 TheScientificWorldJournal
(a)
(b)
Figure3:AP(a)andlateral(b)fluoroscopicimagesshowedthecementspacerbeingremovedandthedefectfilledwithcancellousautograft
harvestedfromiliaccrest.
(a)
(b)
Figure4:AP(a)andlateral(b)radiographstaken6monthslatershowingosseousconsolidation.
factors and could stimulate bone regeneration. Biau et al.
describedthemanagementofa16cmdefectinthefemurofa12-year-old child who had been diagnosed with Ewing’s sar-comaandrequiredresectionofalargesegmentofhisfemur.The segmental defect was stabilized with an intramedullarynailandthenmaintainedwithanantibioticspaceruntillatergraftingandeventualhealing[ 12].However,Accadbledetal.
reported their 3-case study showing that reconstruction ofthe femur seems to be specifically associated with a risk ofgraft resorption. Accadbled et al. [ 13]r e p o r t e dac a s eu s i n g
a cage and nail construct, resulting in successful eradicationof methicillin-resistant staphylococcus aureus infection andreconstitution of a 17cm diaphyseal defect in the tibia [ 14].
As mentioned, the technique has been used to address bone
loss in areas other than long bones. Huffman et al. [ 15]
r e p o r t e du s eo ft h et e c h n i q u ei nas i g n i fi c a n ta r e ao fb o n eloss in the midfoot of a patient who had sustained multiplegunshot injuries. The original description of this techniquedescribed stabilization of the bone with an external fixator,butasnoted,othermeansoffracturefixationhavebeenusedwithsuccess.Apardetal.[ 16]reportedaseriesof12patients
whopresentedwith6cmsegmentaldefectsinthetibia,allofwhom were initially fixed with an intramedullary nail. Theyreported healing following the second-stage procedure in 11of 12 patients at an average of 4 months [ 16]. To our knowl-
edge, no study has evaluated the optimal bio-mechanicalenvironment for such a technique; rather each fracture is“bridged” according to the treating surgeon’s assessment ofthefracture.Apotentialeffectofaconstructthatistoorigidmay be stress shielding near the plate, reducing integrationof the bone graft near the implant. This does not precludebony union but may increase time to osseous consolidationand affect the radiographic appearance of the defect. The
techniqueasdescribedbyMasqueletandBegue[ 5]reliedon
the placement of morselized cancellous autograft harvestedfrom the iliac crests within the biomembrane lined defect.If this amount is not sufficient, demineralized allograft isaddedtotheautograftinaratiothatdoesnotexceed1:3[ 5].
I no u rs t u d y ,w eu s e da u t o g r a fth a r v e s t e dm a i n l yf r o mi l i a ccrest, without any allograft. Biau et al. [ 12]u s e db o t hi l i a c

TheScientificWorldJournal 5
crest corticocancellous autograft and a medial tibial cortical
strut autograft to fill their large defect. Use of cancellousautograftfromthefemoralcanalhasalsobeendescribed,andevidence exists to show that levels of many growth factors(fibroblast growth factor-𝛼, platelet derived growth factor,
insulin-like growth factor 1, TGF-1, and BMP-2) in femoral
cancellous bone are present in higher concentrations than
they are in iliac crest and platelet preparations [ 17]. In our
s e r i e s ,w eu s e dM a s q u e l e tt e c h n i q u et ot r e a tp o s t – t r a u m a t i cbone defect successfully. Further research and clinical serieswillhopefullyelucidatethegraftingcomponentsnecessarytooptimisehealinginthesepatients.
6. Conclusion
Thetechniqueofdelayedbonegraftingafterinitialplacementof a cement spacer provides a reasonable alternative for thechallenging problem of significant bone loss in extremityreconstruction. This technique can be used in either anacute or delayed fashion with equally promising results. Thebioactivity of the membrane created by filling large bonydefects with cement leads to a favourable environment forbone formation and osseous consolidation of a large void.As this technique becomes more widely applied, the answer
to which graft substances to place in the void may become
clearer.Increasingclinicalevidencewillalsohelpsupporttheuseofthistechniqueintreatingsegmentalboneloss.
Conflict of Interests
The authors declare that they have no conflict of interests,anygrant,orfinancialprofitrelatedtothisclinicalstudy.Thisstudy received no specific grant from any funding agency inthepublic,commercial,ornot-for-profitsectors.
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