Masquelet Technique for Salvage of Failed Vascularized Fibular Graft Nonunion After Humeral Tumor Resection

Abstract

Case:

Diaphyseal nonunions after bone tumor resection present a significant reconstructive challenge. We report a 39-year-old woman who developed a diaphyseal humeral nonunion after giant cell tumor resection and reconstruction with vascularized fibula graft. She presented with symptomatic segmental bone loss and hardware failure. Two-stage Masquelet-induced membrane procedure was performed, resulting in complete union and excellent functional recovery at 12 months postoperatively.

Conclusion:

This case highlights the potential of the Masquelet technique in reconstruction of refractory nonunions despite previous failed reconstructive attempts.

Segmental bone defects and nonunion of the upper extremity long bones after bone tumor resection remain among the most challenging problems in orthopedic reconstruction. These cases frequently involve extensive bone loss, compromised local biology, and prior surgical intervention, all of which increase the difficulty of achieving union and restoring function. In this context, selecting an effective salvage strategy after failed reconstruction is critical.

Vascularized fibular grafting (VFG) is a well-established option for reconstructing large segmental defects of the humerus. However, it is a technically demanding procedure associated with prolonged operative times, donor-site morbidity, and a substantial risk of nonunion, particularly in post-tumoral settings where soft tissue and biological conditions are compromised^1,2.

The induced membrane technique described by Masquelet provides an alternative two-stage approach for managing critical-sized bone defects³. The technique relies on the formation of a biologically active membrane around a temporary cement spacer, creating a favorable environment for subsequent bone graft incorporation. Union rates exceeding 80% have been reported across traumatic and oncologic indications^3,4.

This case is notable because it highlights a rare and successful use of the Masquelet technique to salvage a refractory diaphyseal humeral nonunion after giant cell tumor (GCT) resection and VFG reconstruction of the defect.

The patient was informed that data concerning the case would be submitted for publication, and she provided consent.

Case

A 39-year-old right hand dominant female office worker presented to a tertiary referral center with chronic right arm and shoulder pain, weakness, and functional limitation. The patient was diagnosed with a right humeral diaphyseal GCT, 2.5 years before presentation to our clinic. She subsequently underwent tumor excision with segmental resection and reconstruction with a VFG from the contralateral leg, shortly after diagnosis. The pathology result confirmed the initial diagnosis. Six months later, a revision procedure was performed due to ongoing symptoms and nonunion, which involved autologous iliac crest cancellous bone grafting to the humerus. In addition, she reported a history of a childhood humeral fracture in the same site, which was treated nonoperatively with casting; historical records from that time are unavailable.

After the bone grafting surgery, the patient continued to experience right arm and shoulder pain, weakness, and difficulty with overhead activities. She presented to our center approximately 2 years after her revision bone grafting procedure (2.5 years after the initial VFG reconstruction). Physical examination revealed a well-healed right deltopectoral and right iliac crest incisions. Shoulder ROM was limited: forward elevation (FE) 110°, external rotation (ER) 40°, internal rotation (IR) to sacrum level; elbow active ROM 20° to 150°, supination 70°, pronation 80°. Shoulder and elbow strength was reduced: deltoid 4/5, elbow extension 4/5, and supination 4/5. Hand intrinsic and distal motor function was intact (5/5). Grip strength was 22 kg on the right vs. 28 kg on the left. There was reduced sensation in the lateral antebrachial and lateral brachial cutaneous nerve distributions, likely related to previous surgeries, considering anatomical course of upper extremity nerves⁵.

Radiographs demonstrated a nonunion at the distal fibular graft-bone junction with fractured proximal screws and evidence of plate failure (Fig. 1). Nonunion was also confirmed with CT scan showing no osseous bridging between graft and native bone.

Fig. 1.

Preoperative radiographs of the right humerus obtained at the initial clinic visit, 2.5 years after the initial tumor excision and VFG reconstruction. Note the distal graft-bone interface with persistent atrophic nonunion and broken proximal screws with displacement of the plate. VFG, vascularized fibular grafting.

After discussing operative vs. nonoperative options at this stage, the patient was hesitant to proceed with a complex reconstruction. Therefore, she started shoulder physiotherapy sessions, strengthening exercises as well as activity modifications.

After her initial evaluation at our clinic and over the subsequent 12 months, the patient developed progressive pain, worsening functional limitation, and advancing hardware failure, with concern for loss of fixation and further bone compromise. Given these changes, operative intervention was recommended and she elected to proceed with a two-stage Masquelet reconstruction (Fig. 2).

Fig. 2.

Follow-up radiographs of the right humerus, 12 months after the initial visit in our clinic and nonoperative management. Images demonstrate progressive hardware failure with increased displacement as well as persistent nonunion.

The goals of the first-stage procedure were complete excision of nonviable bone, restoration of humeral length and alignment, stable fixation, and creation of a biologically favorable environment for subsequent graft incorporation. The procedure was performed through an extended deltopectoral approach using the prior incision scar. The radial nerve was then carefully explored and protected. The previous hardware was removed aside from 4 broken screws that were well buried and stable in the humeral head and their related residual screw heads that had migrated posterolaterally. The nonunion site with devitalized bone without evidence of intraoperative bleeding was resected with a resultant segmental defect of approximately 8 cm (Fig. 3). A long proximal humerus locking plate (Johnson and Johnson Synthes (Canada) 3.5 mm LCP, 10-Hole) was then applied anterolaterally. Once the bone was clinically stable, and there was still wide access to the bone defect anteriorly, a polymethyl methacrylate (PMMA) cement spacer, hand-mixed with 2 g of vancomycin per packet, was molded to fill the void. Before placing this in situ, a layer of SURGICEL and gauze was interposed posteriorly to protect the radial nerve from potential thermal injury. After this, a 2.4-mm dorsal wrist spanning plate (DePuy Synthes) was placed anteriorly. A wrist-spanning plate was selected for anterior fixation to fit appropriately on the narrow VFG (which was unable to safely accommodate larger-profile hardware), while still allowing for supplemental fixation and load sharing across the defect. We restored length, alignment, and rotational stability (Fig. 4). The wound was closed in layers, and a sterile dressing was applied.

Fig. 3.

Intraoperative picture of the right humerus after hardware removal (above). Intraoperative picture after initial fixation with long proximal humerus plate and before polymethyl methacrylate cement application (below). Yellow lines demonstrate the length of bone defect, with arrows indicating its proximal and distal extent.

Fig. 4.

Postoperative radiographs of the right humerus after the first-stage Masquelet procedure. Note retained broken hardware proximally.

The second stage was performed after 8 weeks. Under general anesthesia, autologous cancellous grafts were harvested anteriorly from the left iliac crest through open approach and the left femur using the Reamer-Irrigator-Aspirator (RIA) second-generation system (RIA 2, DePuy Synthes). The previous deltopectoral incision was reopened, and the anterior spanning plate and cement spacer were removed. The induced membrane was carefully preserved. Copious cancellous bone graft as well as RIA aspirate were packed into the defect. The biological membrane was then carefully reapproximated using running 3-0 Vicryl suture. Dual plating was then re-established with additional locking screws in the anterior plate through unused holes both proximally and distally for improved fixation. The wound was closed in layers. Postoperative radiographs confirmed satisfactory alignment and defect fill (Fig. 5).

Fig. 5.

Postoperative radiographs of the right humerus after the second-stage Masquelet procedure.

Postoperative recovery progressed without complications. The patient participated in a structured rehabilitation program. By 6 months, she reported no pain, had returned to full activities, and resumed her professional duties without restriction.

At the 12-month follow-up, the patient exhibited nearly symmetric shoulder mobility—FE 140°, ER 70°, IR to C6 level—and full elbow motion (Fig. 6). Motor strength was 5/5 throughout the extremity. Grip strength measured 18 kg on the right compared with 20 kg on the left, demonstrating near-symmetric functional strength despite slightly lower absolute values compared with preoperative testing. Residual numbness in the lateral antebrachial cutaneous nerve distribution remained stable and nondisabling. Radiographs confirmed complete radiographic union across the graft-bone junction (Fig. 7). In addition, the patient’s 12-month Disabilities of the Arm, Shoulder, and Hand score improved from 66.7 preoperatively to 6.9, consistent with minimal residual disability and excellent functional recovery.

Fig. 6.

Clinical photograph obtained 12 months after the second stage of the Masquelet reconstruction, demonstrating restored shoulder range of motion (FE, ER and IR). FE, forward elevation; ER, external rotation; IR, internal rotation.

Fig. 7.

Twelve-month post–second-stage Masquelet radiographs from the same visit displayed in Figure 6, demonstrating complete bony healing with osseous bridging and stable fixation.

Discussion

The Masquelet-induced membrane technique provides a staged approach for managing critical-sized bone defects and complex nonunion. The biologically active membrane formed around the cement spacer promotes angiogenesis and osteogenesis, creating an environment conducive to graft incorporation. While originally popularized for lower-extremity reconstruction, its application in the upper extremity has expanded⁶.

A recent systematic review of VFGs for the treatment of long bone defects, involving 2,226 patients reported that nonunion occurred in nearly 20% of cases, and the failure rate may be higher in post-tumor settings due to compromised local biology and soft tissue status⁷.

Originally popularized for the lower limb, the induced membrane technique has increasingly been applied in the upper extremity. Although reported outcomes of the Masquelet technique in the upper extremity are favorable, most published cases involve relatively small defects. In recent systematic reviews, the average humeral defect length treated with this technique was approximately 2.5 cm^8,9. By contrast, the present case involved an approximately 8-cm defect in a post-tumor setting, expanding the potential indications for this approach.

VFG reconstruction is an established option for humeral nonunion with segmental bone loss, with high union rates reported in experienced microsurgical centers. However, VFG requires specialized expertise and is associated with prolonged operative times and donor site morbidity. In a series of 23 patients treated with vascularized grafts for recalcitrant humeral nonunion, union was achieved in 21 cases (91%), albeit the need for 2 operative sites and lengthy procedures¹⁰. By contrast, the two-stage Masquelet technique does not require microsurgical reconstruction and is easier and more resource-efficient. Although Masquelet first introduced this innovative induced-membrane technique in the mid-1980s, few cases of Masquelet application after VFG have been reported to date². The present case demonstrates the effectiveness of this approach as a salvage strategy after refractory nonunion of a VFG in a complex revision setting.

Conclusion

This case demonstrates that the Masquelet-induced membrane technique can be successfully applied as a salvage strategy after failure of VFG reconstruction in a complex diaphyseal nonunion. Careful patient selection, meticulous debridement, restoration of stability, and appropriate biological augmentation are essential for success.