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. 2026 May 23;26:484. doi: 10.1186/s12893-026-03838-8

Slow debridement combined with hemi-Masquelet technique for post-traumatic chronic osteomyelitis calcaneal bone defect

Xi Yang 1, Yuancheng Li 2, Yu Liu 2, Fang Yang 2, Wei Zhou 2, Nan Li 2,✉
PMCID: PMC13374313  PMID: 42177466

Abstract

Background

The treatment of calcaneal osteomyelitis presents considerable challenges to orthopedic surgeons. The objective of this study was to explore an effective approach for the radical treatment of the disease and to examine a novel bone grafting strategy for better functional recovery.

Methods

Between 2021 and 2025, 9 patients with chronic calcaneal osteomyelitis were treated via slow debridement combined with the Masquelet technique using structural bone grafting. The number of debridement, complications during treatment, and recurrence rates were recorded and analyzed. Postoperative hindfoot function was assessed by using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system.

Results

All 9 (100%) patients achieved infection eradication after an average of 1.7 (range, 1–3) debridement. Preoperative infectious symptoms, including sinus tracts, redness and swelling, were generally eliminated. All patients achieved bony healing of the calcaneal defect and could tolerate full weight bearing without pain within one year after surgery. The average AOFAS ankle and hindfoot score was 93 (range, 86–100), and the calcaneal defects of all 9 patients achieved bony healing.

Conclusions

Slow debridement combined with the Masquelet technique using via structural bone grafting is an effective method for treating posttraumatic chronic calcaneal osteomyelitis. The application of this technique can lead to the complete elimination of infection as well as the preservation of hindfoot function in a cost-effective manner for patients with posttraumatic chronic calcaneal osteomyelitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-026-03838-8.

Keywords: Chronic calcaneal osteomyelitis, Slow debridement, Masquelet technique, Bone defect

Introduction

In clinical practice, calcaneal fractures are common – they account for 0.4–2% of all fractures 60–75% of tarsal bone-related fractures [1–3]. With regard to intra-articular fractures with displacement, the current methods for managing calcaneal fractures include classical open reduction and internal fixation (ORIF) through the lateral approach [4], closed reduction and internal fixation (CRIF) [5], or a combination of internal and external fixation [6]. However, the complications associated with these treatments should be taken seriously. Chronic osteomyelitis is one of the most challenging complications, as it accounts for 3–11% of all bone infections [7, 8].

Owing to the limited blood supply of cancellous bone, relatively poor coverage of the surrounding soft tissues and distinctive anatomical characteristics, pathogens are difficult to eradicate, resulting in an infection relapse rate of over 20% [9, 10]. Although debridement surgery has been demonstrated to be the optimal solution for managing chronic calcaneal osteomyelitis, treatment failure, especially infection recurrence, continues to pose significant challenges for orthopedic surgeons and can lead to devastating outcomes such as partial or total calcanectomy, amputation, loss of function or even death [9, 11]. To cure this intractable disease from the root, complete or even radical debridement is essential; however, extensive debridement results in bone defects. Fortunately, the Masquelet technique has been proven to be an effective method for managing bone defects, especially in cases of bone infection [12]. The Masquelet technique contains two stages: in the first stage, complete debridement and polymethyl methacrylate (PMMA) spacer filling are performed; the second stage occurs 6–8 weeks later and involves the removal of the spacer as well as the implantation of the bone graft.

The classical Masquelet technique is often applied for long bone defects. A bone graft substitute consisting of a demineralized allograft and an autograft at a 1:3 ratio is recommended; it takes at least 3–6 months to obtain initial mineralization of the grafts, and the time to achieve full weight bearing depends on the location and soft tissue condition of the limb [12].

The aim of this study is to assess the outcomes of a two-stage debridement strategy defined as “slow debridement” combined with a novel bone graft strategy for the management of chronic calcaneal osteomyelitis.

Methods

Patients

From December 2021 to October 2025, 26 patients with chronic calcaneal osteomyelitis were treated in our department. The inclusion criteria were as follows: (1) definitive diagnosis of chronic calcaneal osteomyelitis; (2) minimum follow-up duration of 12 months after the last operation; and (3) slow debridement combined with structural bone grafting via the Masquelet technique was performed. The exclusion criteria were as follows: (1) cardiovascular disease, diabetes mellitus, or other serious systemic diseases; (2) treatment with a relatively conservative surgical plan, such as debridement or flap surgery only.

Ultimately, 9 patients with chronic calcaneal osteomyelitis who met eligibility criteria were included in this study. There were 8 males (88.9%) and 1 (11.1%) female, and the average age was 44.9 years (range, 20–59 years). Five (55.6%) patients had lesions on the right foot, and 4 (44.4%) patients had lesions on the left foot. The causes included open reduction and internal fixation (ORIF) (7 patients) and open fractures (2 patients). Before being transferred to our department, all 9 patients experienced treatment failure, with an average of 2.3 debridements (range, 1–4). A draining sinus was the most common local presentation (8 patients), and ulcers were observed in 1 patient. On average, symptoms had persisted for 8.9 months (range, 3–13 months) before admission to our department. Preoperative laboratory tests revealed that only 1 patient had an abnormal erythrocyte sedimentation rate (ESR), and all other patients had normal results on all tests. The characteristics of the patients are summarized in Table 1.

Table 1.

Patient characteristics and outcomes

Patient Age Sex Side Etiology Times of debridement before admission Symptoms duration before admission (months) Organisms Flap type Positive inflammatory markers Times of debridement Fracture during treatment Duration before bone grafting(weeks) Follow-up duration (months) Outcome of treatment AOFAS score
1 46 M L ORIF 4 8 S. epidemidis PAP None 2 Yes 12 18 Remission 93
2 48 M R Open fracture 3 12

S. aureus

E. cloacae

K. pneumoniae

 PAP None 3 Yes 10 24 Remission 100
3 38 M L ORIF 2 10 S. aureus PAP None 1 No 8 32 Remission 96
4 51 M L Open fracture 1 3 P. aeruginosa SN ESR 1 No 12 12 Remission 93
5 46 M R ORIF 3 10

S. aureus

A. baumannii

 PAP None 2 No 9 22 Remission 90
6 49 M R ORIF 1 13 S. epidemidis PAP None 2 No 10 15 Remission 96
7 20 M R ORIF 3 9

S. epidemidis

E. coli

 PAP None 1 No 10 12 Remission 93
8 59 F L ORIF 2 5 S. aureus SN None 1 No 12 13 Remission 86
9 47 M R ORIF 2 10 S. aureus PAP None 2 Yes 10 16 Remission 90
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Abbreviations: A. baumannii: Acinetobacter baumannii, CRP C-reactive protein, E. cloacae: Enterobacter cloacae, E. coli: Escherichia coli, ESR Erythrocyte sedimentation rate, F Female, K. pneumoniae: Klebsiella pneumoniae, L Left, M Male, ORIF Open reduction and internal fixation, P. aeruginosa: Pseudomonas aeruginosa, PAP Peroneal artery perforator flap, R Right, S. aureus: Staphylococcus aureus, S. epidermidis: Staphylococcus epidermidis, SN Sural neurocutaneous flap

After admission to our department, all patients underwent physical examinations, X-rays, computerized tomography (CT) scans, magnetic resonance imaging (MRI), pathogenic microorganism cultures and laboratory tests. The microbiological culture results are presented in Table 1. One of the most distinctive features of chronic calcaneal osteomyelitis is chronic long-term infection, and inflammation results or systemic manifestations are rare [13].

Surgical procedure

The surgery was performed by 2 experienced surgeons using spinal, nerve block, or general anesthesia. The surgical procedures are illustrated in Fig. 1. The condition around the incision was assessed first, considering that all the patients had experienced infection elimination failure before admission. Extended debridement was performed, and at least 1 cm of the skin around the sinus or ulcer was resected (Figs. 2A and 3A). Devitalized cortical bone, infected cancellous bone and the adjacent area of infected cancellous bone were eliminated using an osteotome and spatula. Both soft tissue and bone were freshened, and the observation of fresh oozing blood was required during surgery. Bone and soft tissue samples were subjected to histological examination and culture to verify the diagnosis and guide further treatment. The wound was then irrigated with sterile saline solution and hydrogen peroxide alternatively and soaked in 50% iodophor for 5 min.

Fig. 1.

Fig. 1

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Flow chart of the surgical procedure

Fig. 2.

Fig. 2

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Skin sinus of the patient (A); Preoperative X-ray (B)

Fig. 3.

Fig. 3

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Infectious focus of the left calcaneus after removal of the lateral skin (A); first debridement (B); second debridement (C); X-ray after debridement (D)

After debridement of the unhealthy skin, fascia, tendons and infected bone (Fig. 3B), multipoint bacterial culture was performed the next three days immediately during the daily process of dressing changes to assess the effect of debridement. We chose percutaneous bone biopsies for it is more reliable than superficial swab cultures or needle punctures for identifying the causative agent of osteomyelitis [14, 15]. The points used for culture should cover the inside of the wound and be marked, at least 5 points were recommended. This process usually took one week, if all the culture results were negative, the procedure was continued; or a second debridement would be performed with another 2 to 3-mm of tissue excised depending on the positive points (Fig. 3C) until three consecutive culture results were negative. The average number of debridement to achieve complete elimination of infections in this study was 1.7 (range, 1–3). This two-stage debridement strategy was defined as “slow debridement” and used to minimize the probability of infection recurrence.

The next surgical procedure was not performed until the culture results were negative. The cavity was filled with a spacer made of polymethylmethacrylate (PMMA) and vancomycin at a ratio of 10:1 (Fig. 4A). Because the scope of debridement for soft tissue is relatively large, a flap was needed in most cases, and an artery perforator flap/sural neurocutaneous/free flap was transplanted according to the position of the defect (Fig. 4D). Six to eight weeks later, the condition within the wound was reassessed. If there was no obvious recurrence of infection within the wound and if the appearance of the induced membrane was a healthy white color (Fig. 5A), autogenous iliac crests with intact cortical bone were harvested and modified to the required shape according to the shape of the defect in the calcaneus, after which the cavity was filled with internal fixation. Fixation was achieved with two 6.5-mm cancellous bone screws through the posterior cortex of the calcaneus, full-thickness iliac crests and subchondral bone of the calcaneocuboid articular surface, the screws played a role similar to that of a beam, which can enhance the stability of the structural bone graft. The remaining cavity was filled with autologous or allogeneic cancellous bone (Fig. 5B-E). Otherwise, if the induced membrane was unhealthy (Fig. 5G), the steps of debridement and spacer filling were repeated until any potential risk of infection was eliminated. The donor area is filled with PMMA to maintain the integrity and continuity of the iliac crest. (Fig. 5F).

Fig. 4.

Fig. 4

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The antibiotic bone cement spacer was placed (A); peroneal artery perforator flap surgery was designed and performed (B, C and D); and postoperative X-ray (E) was performed

Fig. 5.

Fig. 5

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The induced membrane (A); the iliac crest bone from the patient (B); the iliac crest bone was implanted and fixed with calcaneal screws (C); the rest of the cavity was filled with autogenous iliac cancellous bone (D); postoperative X-ray of the calcaneus (E); and postoperative X-ray of the iliac bone defect was filled with bone cement spacers (F)

Postoperative management

Postoperatively, imaging and laboratory examinations were performed.Although it has been reported that the application of antibiotics for 6 weeks improves the outcome of chronic osteomyelitis; however, the optimal duration of postoperative antibiotic therapy remains uncertain [16]. In this study, none of the patients had systemic inflammatory manifestations; all of them had received irregular antibiotics before admission and showed no improvements in terms of eliminating the infection. Therefore, one week of intravenous antibiotic therapy was applied to prevent the systemic spread of osteomyelitis after the first debridement, there were no subsequent oral antibiotic therapy used afterwards as maintenance therapy. Partial weight-bearing was encouraged immediately after the bone cement was filled and the structural bone was grafted. The drain was not removed until the volume was less than 10 ml per day, which took 3–7 days regularly.

Clinical evaluation

Patients were requested to undergo regular follow-up in our department for independent assessment. The subjective reports of patients and objective results, such as clinical, imaging and laboratory examinations, were obtained. Hindfoot function assessment was performed at least 12 months after the last operation using the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Both the absence of any signs of infection and a completely healed wound was necessary to define the cure of the disease. Treatment failure was defined as the recurrence of any positive clinical symptoms or elevated inflammatory markers.

Results

The average follow-up duration was 18.2 months (range, 12–32 months). All 9 patients achieved complete remission after an average of 1.7 (range, 1–3) debridement. Since all the patients experienced surgical failure and the skin and soft conditions were relatively poor, a local transfer flap was performed in all cases. Notably, 5 (55.6%) patients complained of feeling like stepping on hard stones when walking after the bone cement was implanted; moreover, 3 (33.3%) patients experienced slight stress-related calcaneal fractures before structural bone grafting (Fig. 6A-C), which had little impact on the final recovery. Prolonged drainage was needed in all patients after bone cement implantation, which was successfully managed with regular dressing changes for 3–7 days postoperatively.

Fig. 6.

Fig. 6

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Lateral (A) and back (B) views and the squatting function of the patient (C)

Structural bone grafting was performed an average of 10.3 weeks (range, 12–32 weeks) after bone cement implantation. X-ray imaging was conducted every 3 months postoperatively, whereas only 4 (44.4%) patients underwent CT. Bone healing was observed 12 months after bone grafting. The average AOFAS hindfoot score was 93 points (ranging from 86 to 100 points), demonstrating that hindfoot function was preserved in most patients.

All 9 patients had positive culture results, with a total of 7 bacterial species. Staphylococcus aureus (5/9, 55.6%) was the most common pathogen, followed by Staphylococcus epidermidis (3/9, 33.3%), Klebsiella pneumoniae (1/9, 11.1%), and Enterobacter cloacae (1/9, 11.1%), Pseudomonas aeruginosa (1/9, 11.1%), Acinetobacter baumannii (1/9, 11.1%), and Escherichia coli (1/9, 11.1%). The culture results were negative in 1 patient, and polymicrobial infections were found in 3 patients. Antimicrobial susceptibility testing revealed that all bacterial species were sensitive to vancomycin or gentamicin.

Discussion

According to previous studies, calcanectomy and debridement are the two primary surgical strategies for chronic cancellous osteomyelitis [17]. Additionally, the risk of infection recurrence following calcanectomy is significantly greater than that following debridement [9]; therefore, debridement has become the mainstream surgical strategy. Despite significant advances in surgical techniques, there have been no significant breakthroughs in debridement procedures for treating calcaneal osteomyelitis. Although guidelines for the extent of surgical resection of long bone osteomyelitis have been reported [18], the extent of debridement for cancellous bone remains difficult to define, and both incomplete and excessive debridement make subsequent treatment more intractable. The first debridement should be as complete as possible, and a second debridement should be performed on the basis of the multipoint culture outcomes after the first debridement, which should be limited and localized to minimize the recurrence of infection and preserve healthy tissue as much as possible. This two-stage debridement procedure, which sacrifices time in exchange for a low recurrence rate, is defined as "slow debridement". Previous study reported an overall pathogen culture positive rate of 80.2%; however, all the patients in our study had definitive positive pathogen culture outcomes, possibly because there are different causes of chronic calcaneal osteomyelitis, while our cases were caused by trauma [9].Although the overall positive rate of culture for chronic osteomyelitis of the calcaneus is relatively unsatisfactory, more advanced techniques, such as ultrasound and metagenomic next-generation sequencing (mNGS), have been proven to effectively increase the rate of bacterial cell growth, which could be adopted to improve the positive rate of culture [19, 20]. These developing detection technologies will further increase the efficiency of "slow debridement" and reduce the recurrence rate of this rebellious disease.

A relatively aggressive debridement strategy can lead to both soft and bone defects, which makes obtaining an infection-free limb with good preservation of hindfoot function difficult. With respect to soft tissue defects, a flap can not only solve this problem but also provides stronger anti-infection capability because of its rich blood supply, especially for patients who experience failed surgical treatments. Regarding bone defects of the calcaneus, the situation is much more complicated. Researchers have developed a variety of ways to solve this problem, such as antibiotic-loaded calcium sulfate and 3D printing-assisted shaping of titanium cages, which have achieved satisfactory results [21, 22]. However, owing to the high economic cost or complex preoperative design, as well as the high demand for equipment hardware, these methods are difficult to apply in many grassroots hospitals, as most patients suffering from chronic calcaneal osteomyelitis have experienced times of treatment failure and have poor financial situations.

Compared with classical bone defect reconstruction strategies, such as blood-vascularized free bone grafting or the Ilizarov technique, the Masquelet technique has been proven to be simple to perform and reliable for long bone defect reconstruction [12, 23]. The procedure involves two stages. In the first stage, a PMMA spacer is implanted in the area of the bone defect. This spacer prevents the infiltration of granulation tissue and maintains the length of the bone, and the membrane formed under the stimulation of PMMA contains osteoprogenitor cells that release inductive molecules capable of stimulating osteogenesis [24, 25]. The second stage is performed 6–8 weeks after PMMA spacer implantation, when the growth factors accumulated in the cavity reach their highest level and vascularization of the induced membrane has been fully completed [24]. With the membrane dissected and the PMMA spacer removed, autogenous cancellous bone grafts harvested from the iliac crest are filled in the bone defect area. The induced membrane prevents resorption of the bone graft and promotes the mineralization process [24]. If the quality of the induced membrane is not as healthy as expected, this procedure is suggested to be repeated with the unhealthy membrane excised because any possibility of infection recurrence should be minimized. In our study, patients frequently complained of discomfort when walking, and 3 of them (33.3%) even suffered from periprosthetic fracture during the process of PMMA implantation (Fig. 7A-B). Their poor compatibility with bone tissue demonstrated that PMMA is not an ideal final implant for defects of the calcaneus.

Fig. 7.

Fig. 7

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A stress fracture occurred after the bone cement implantation (A and B)

The classical bone graft used in the Masquelet technique is autologous cancellous bone with or without a small proportion of heterologous cancellous bone [12, 26]. As the research progressed, large cortical bone has been proven to be as effective as cancellous bone grafts due to its excellent anti-absorption ability and greater structural stability [27–29], which facilitate earlier weight-bearing and better functional recovery. All these innovations involve the application of the Masquelet technique in long bone defects; however, there is still a lack of experience with irregular bone defects when using Masquelet technique. In cases of long bone defects, the inducing membrane is capable of completely enveloping the entire graft; regarding defects in the calcaneus, the inducing membrane is only able to cover 1–2 surfaces of the entire segment of the transplanted iliac bone (Fig. 5A), this innovation to the traditional Masquelet technique can be defined as “hemi-Masquelet technique”. The follow-up results demonstrated the powerful ability of this modified Masquelet technique to promote grafted bone healing. Patients are able to start full weight bearing 3 months postoperatively with the supporting strength of the cortical bone which lead to well preserved function of the hindfoot. The bony union sign from X-Ray (Fig. 8) and CT re-examination (Fig. 9A and B) further confirmed that structural bone grafting via hemi-Masquelet technique is an effective method for the management of bone defects caused by chronic calcaneal osteomyelitis. Meanwhile, the continuity of the iliac crest the donor area well preserved (Fig. 9C).

Fig. 8.

Fig. 8

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X-rays after 1 (A), 3 (B), 6 (C), and 12 (D) months

Fig. 9.

Fig. 9

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CT scan after 12 months demonstrating healing of the bone graft (A); X-ray of the ilium after 12 months (B)

Although definite advantages for the treatment of chronic calcaneal osteomyelitis have been made by previous researchers, to our knowledge, this is the first study to carry out this gradual debridement strategy combined with structural bone grafting via the Masquelet technique. This approach eliminates the risk of recurrence and allows the calcaneus to return to a physiological structure close to normal. The main disadvantage of this strategy is that it is a two-stage treatment that is more time-consuming than one-stage treatment strategies. Additionally, this was a retrospective study with a relatively small number of cases, and the efficacy of this approach was not compared with the efficacy of other surgical methods.

Conclusions

Slow debridement combined with the Masquelet technique using structural bone grafting is effective for the treatment of posttraumatic chronic calcaneal osteomyelitis. Compared to other treatment strategies, it provides a relatively simple and cost-effective treatment for patients with posttraumatic chronic calcaneal osteomyelitis. With the development of technology, this method is expected to be improved and applied more widely.

Supplementary Information

Supplementary Material 1. (3.3MB, pptx)

Acknowledgements

Not applicable.

Authors’ contributions

Nan Li designed the study and performed the surgery; Xi Yang assisted the surgery and wrote the manuscript; Yuancheng Li and Yu Liu assisted designing and performed the operation; Fang Yang performed the follow-up and collect the data; Wei Zhou provided imaging support and analysis.

Funding

This research received no funding support.

Data availability

All data generated or analyzed during this study are included in this published article. The data used and/or analyzed during the study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was performed in accordance with the World Medical Association (WMA) Declaration of Helsinki. The requirement for ethical approval was waived by the Ethics Committee of 96603 Military Hospital of PLA due to the retrospective nature of the study. All procedures were conducted in accordance with relevant national guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  • 1.Zheng W, Xie L, Xie H, Chen C, Chen H, Cai L. With versus without bone grafts for operative treatment of displaced intra-articular calcaneal fractures: a meta-analysis. Int J Surg. 2018;59:36–47. [DOI] [PubMed] [Google Scholar]
  • 2.Vicenti G, Carrozzo M, Solarino G, et al. Comparison of plate, calcanealplasty and external fixation in the management of calcaneal fractures. Injury. 2019;50(Suppl 4):S39–46. [DOI] [PubMed] [Google Scholar]
  • 3.Vosoughi AR, Shayan Z, Salehi E, Jaberi FM, Solooki S, Kardeh B. Agreement between Sanders classification of intraarticular calcaneal fractures and assessment during the surgery. Foot Ankle Surg. 2020;26(1):94–7. [DOI] [PubMed] [Google Scholar]
  • 4.Dhillon MS, Bali K, Prabhakar S. Controversies in calcaneus fracture management: a systematic review of the literature. Musculoskelet Surg. 2011;95(3):171–81. [DOI] [PubMed] [Google Scholar]
  • 5.Long C, Li K, Zhu J, Liu H, Zhu Y. Three-step closed reduction and percutaneous screw fixation: a reliable and reproducible protocol in managing displaced intra-articular calcaneal fractures. Injury. 2023;54(Suppl 2):S49–55. [DOI] [PubMed] [Google Scholar]
  • 6.Kim GB, Park JJ, Park CH. Intra-articular calcaneal fracture treatment with staged medial external fixation. Foot Ankle Int. 2022;43(8):1084–91. [DOI] [PubMed] [Google Scholar]
  • 7.Torre A, De Monti M. Osteomyelitis of the calcaneus with pathologic fracture. J Foot Ankle Surg. 2020;59(3):641. [DOI] [PubMed] [Google Scholar]
  • 8.McCann MJ, Wells A. Calcaneal osteomyelitis: current treatment concepts. Int J Low Extrem Wounds. 2020;19(3):230–5. [DOI] [PubMed] [Google Scholar]
  • 9.Jiang N, Chen P, Liu GQ, et al. Clinical characteristics, treatment and efficacy of calcaneal osteomyelitis: a systematic review with synthesis analysis of 1118 reported cases. Int J Surg. 2024;110(10):6810–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Emslie KR, Fenner LM, Nade SML. Acute haematogenous osteomyelitis: II. the effect of a metaphyseal abscess on the surrounding blood supply. J Pathol. 1984;142(2):129–34. [DOI] [PubMed] [Google Scholar]
  • 11.Fukuda T, Reddy V, Ptaszek AJ. The infected calcaneus. Foot Ankle Clin. 2010;15(3):477–86. [DOI] [PubMed] [Google Scholar]
  • 12.Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am. 2010;41(1):27–37 table of contents. [DOI] [PubMed] [Google Scholar]
  • 13.Jiang N, Ma YF, Jiang Y, et al. Clinical characteristics and treatment of extremity chronic osteomyelitis in Southern China: a retrospective analysis of 394 consecutive patients. Medicine (Baltimore). 2015;94(42):e1874. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Senneville E, Melliez H, Beltrand E, et al. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis. 2006;42(1):57–62. [DOI] [PubMed] [Google Scholar]
  • 15.Senneville E, Morant H, Descamps D, et al. Needle puncture and transcutaneous bone biopsy cultures are inconsistent in patients with diabetes and suspected osteomyelitis of the foot. Clin Infect Dis. 2009;48(7):888–93. [DOI] [PubMed] [Google Scholar]
  • 16.Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2012;54(3):393–407. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Drampalos E, Mohammad HR, Kosmidis C, Balal M, Wong J, Pillai A. Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: the Silo technique. Foot (Edinb). 2018;34:40–4. [DOI] [PubMed] [Google Scholar]
  • 18.Simpson AH, Deakin M, Latham JM. Chronic osteomyelitis. The effect of the extent of surgical resection on infection-free survival. J Bone Joint Surg Br. 2001;83(3):403–7. [DOI] [PubMed] [Google Scholar]
  • 19.Pitt WG, Ross SA. Ultrasound increases the rate of bacterial cell growth. Biotechnol Prog. 2003;19(3):1038–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Ruan Z, Shi H, Chang L, et al. The diagnostic efficacy of metagenomic next-generation sequencing (mNGS) in pathogen identification of pediatric pneumonia using bronchoalveolar lavage fluid (BALF): a systematic review and meta-analysis. Microb Pathog. 2025;203:107492. [DOI] [PubMed] [Google Scholar]
  • 21.Qin C-H, Zhou C-H, Ren Y, et al. Extensive eggshell-like debridement technique plus antibiotic-loaded calcium sulphate for one-stage treatment of chronic calcaneal osteomyelitis. Foot Ankle Surg. 2020;26(6):644–9. [DOI] [PubMed] [Google Scholar]
  • 22.Zhao J, Wang Z, Long C, He H, Zhao W, Zhang J. Using 3D printing-assisted shaping titanium cages and Masquelet techniques to reconstruct calcaneal osteomyelitis complicated by extensive soft tissue and uncontrolled defects. Injury. 2023;54(10):110977. [DOI] [PubMed] [Google Scholar]
  • 23.Villemagne T, Bonnard C, Accadbled F, L’Kaissi M, de Billy B, Sales de Gauzy J. Intercalary segmental reconstruction of long bones after malignant bone tumor resection using primary methyl methacrylate cement spacer interposition and secondary bone grafting: the induced membrane technique. J Pediatr Orthop. 2011;31(5):570–6. [DOI] [PubMed] [Google Scholar]
  • 24.Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res. 2004;22(1):73–9. [DOI] [PubMed] [Google Scholar]
  • 25.Cuthbert RJ, Churchman SM, Tan HB, McGonagle D, Jones E, Giannoudis PV. Induced periosteum a complex cellular scaffold for the treatment of large bone defects. Bone. 2013;57(2):484–92. [DOI] [PubMed] [Google Scholar]
  • 26.Azi ML, Teixeira AAA, Cotias RB, Joeris A, Kfuri M. Induced-membrane technique in the management of posttraumatic bone defects. JBJS Essent Surg Tech. 2019;9(2):e22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Gannamani S, Rachakonda KR, Tellakula Y, Takkalapally H, Maryada VR, Reddy AVG. Combining non-vascularized fibula and cancellous graft in the Masquelet technique: a promising approach to distal femur compound fracture management with large defects. Injury. 2024;55(2):111233. [DOI] [PubMed] [Google Scholar]
  • 28.Zong HY, Liu Y, Yin X, Zhou W, Li N. Masquelet technique using an allogeneic cortical bone graft for a large bone defect: a case report. World J Clin Cases. 2025;13(5):99963. [DOI] [PMC free article] [PubMed]
  • 29.Ramos O, Mariorenzi M, Johnson JP, Hayda RA. Adding a fibular strut allograft to intramedullary nail and cancellous autograft during Stage II of the Masquelet technique for segmental femur defects: a technique tip. J Am Acad Orthop Surg Glob Res Rev. 2020;4(7):e1900179. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1. (3.3MB, pptx)

Data Availability Statement

All data generated or analyzed during this study are included in this published article. The data used and/or analyzed during the study are available from the corresponding author on reasonable request.

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