CORR Insights^®: The Effect of Surgical Technique and Spacer Texture on Bone Regeneration: A Caprine Study Using the Masquelet Technique

Where Are We Now?

The Masquelet-induced-membrane technique (commonly referred to as the Masquelet technique) is an emerging alternative surgical approach to bone transport of distraction osteogenesis for traumatic segmental long-bone defects [3]. The Masquelet technique seems especially advantageous, since it calls for shorter periods of external fixation. The induced osteogenic membrane acts as a bioreactor producing both osteoinductive peptides and angiogenetic growth factors. Generally, surgeons can fill the well-vascularized envelope with autologous morcellized bone graft. The defect healing also requires maintenance of adequate mechanical stability.

The Masquelet technique may help to rebuild a long-bone after high-energy extremity trauma. In fact, the technique seems to work even in reconstructions following wide débridement of infected nonunions when combined with adequate antimicrobial therapy and soft-tissue reconstruction [2].

Where Do We Need To Go?

Despite these benefits, a number of questions still remain. At what point should the second stage of the procedure be performed, and what criteria should be used to determine when it is appropriate to perform it? What is the ideal type of spacer with, and without, antibiotics? Additionally, we still do not know the best graft material for filling the defect, including the additional use of reamer/irrigator/aspirator-assisted bone graft harvesting, concentrated bone marrow, recombinant bone morphogenetic protein products, or synthetic bone graft substitutes [2].

Generally, the patient must tolerate a long and difficult reconstruction process, and there is a persistent risk of nonunion [5], although union is achieved in about 90% of patients [4]. Therefore, it is important to learn how to maximize the osteogenic power of the technique. Patients must be also informed about other complications, including persistent infection and the potential for permanent functional disabilities.

The goat model used in the current study should be further characterized in terms of restoration of bone biomechanical properties and compared to the contralateral intact tibia. By doing so, we can develop a solid base for preclinical evaluation of different factors, which could potentially accelerate or delay union under clinical conditions.

How Do We Get There?

Case reports, case series, and observational studies of more than 400 treated adult patients [3] have not given definitive answers to the questions that remain about the Masquelet technique. Conducting randomized trials of patients with traumatic segmental long-bone defects will be challenging, as these injuries are generally quite rare, making prospective studies of their treatment difficult to produce [3].

The NIH [6] and the European Union [1] have done an excellent job establishing guidelines for the use of experimental animals in research. Although strictly regulated, negative public opinion on the use of animal experiments in orthopaedic research has likely made an impact on the willingness of investigators to apply especially large-animal models. However, we should not hesitate to select this research approach when necessary. The case of the induced membrane technique is an example when the application of animal models is called for.

Beyond that, we need systematic large-scale investigation for testing of the critical components of the Masquelet technique under standardized conditions. The research needs a relevant large-animal model, like the one applied in the current study. The key is to get the commitment of leading research institutes and investigators to share the same animal model, including a standardized treatment of the control group. The investigators could pick up and execute one or two of the planned experiments according to their expertise and interest. As a replacement for investigator-initiated projects, a multi-institutional international collaboration would require coordination from potential sponsors, such as the NIH, European Union, and the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Foundation.