Abstract
Introduction
The Masquelet technique based on induced membrane is performed in two stages, first with generally an external fixator which is more and more relayed by an internal fixator. The aim of this study is to assess the results of stabilization by using intramedullary nailing from the first stage.
Patients and methods
Nine patients were treated for a bone defect concerning 8 femurs and one tibia. The mean size of bone defect was 9.25 cm. It was secondary to a fracture (6 case) with bone defect and two septic and aseptic pseudarthrosis. In all cases the nailing was performed at the first stage of Masquelet. Prior to cement delivery, the site was thoroughly cleaned with iterative excisions as needed. Blood count control, normal CRP and negative culture were required before cement delivery. The cement was placed around the nail and encased the bony extremity. In the second stage, after removal of the cement, the defect was fulfilled by a mixture of cortico-cancellous autogenous graft taken from the iliac crest and phosphocalcic bone substitute. The nail was not changed in any patient. In post operative the mobilization of the above and underlying joints was immediate.
Results
No sepsis was detected before the second time. Early weight bearing was allowed on average at the end of the 2 nd month. Total bearing without support was allowed at a mean of 5.5 months. All patients have consolidated. One patient had a shortening of 2.35 cm. The mean follow-up was 46.1 months. The average period to effective return to work was 21 months.
Conclusion
The nailing performed at the first stage of the induced membrane technique (IMT) gives good results. This modification does not seem to increase the risk of infection. These good results deserve to be confirmed by other studies to confirm the interests of associating nailing to IMT from the first stage.
Keywords: Bone defect, Bone reconstruction, Induced membrane, Nailing
1. Introduction
The reconstruction of post-traumatic shaft's bone defect after infection or after tumor resection is a challenge for the surgeon and the patient. Various techniques have been described in this treatment: bone transfer of the vascular fibula with Illizarov's fixator; free vascular or non-vascular fibula graft, autogenous graft, composite cutaneous-osteomuscular graft.1,2 The induced membrane technique (IMT) reported by Masquelet & al in 19861 describes a reconstruction in two stages. This induced membrane has a dual biological and mechanical action. It is richly vascular and secretes growth factors (VEGF, TGF-β1). It prevents the resorption of the cancellous bone and stimulates the proliferation of scar cells.1 IMT is widely used as witnessed by numerous publications reporting positive results.2 Many variants and technicals details of authors have contributed to improve the procedure and widen the indications, and so open the way to other perspectives. Stabilization of the fragments during all procedures at the beginning of this IMT was done by external fixator which is maintained until weight bearing and consolidation.1 This fixation extends the delay of the weight bearing and consolidation time,1 requires multiples monitoring and is uncomfortable for the patient. To reduce these complications, it is relayed most often in the second stage by an internal fixator. Some authors in a modified technique reported satisfactory results of internal fixator by intramedullary nailing from the first stage3,4,.5 The aim of this study was to evaluate the results of the nailing associated with the technique of Masquelet from the first stage, to specify the tips and tricks, and to confirm the advantages of this modified technique.
2. Patients and methods
2.1. Patients
Between 2000 and 2016, eight patients were treated by the induced membrane technique at Pointe-à-Pitre Teaching Hospital, for a diaphyseal bone defect. There were seven men and one woman with 30 years average age. The defect concerned 7 femurs (Fig. 1) and on the proximal tibia. The average length of bone defect was 9.25 cm (7–12 cm) either directly from trauma or after debridement and excision of necrotic or infected bone. Two defects were secondary to femoral non-union, one of which was septic. There was no case of osteitis or osteomyelitis. Table 1 summarizes the epidemiological aspect of patients.
Fig. 1.
A: gun shot complex diphyseal femur fracture. B: AP X-ray showing cement around the nail after 1st stage. C: 9cm bone defect after removing cement in second stage.
Table 1.
Epidemiological characteristics of patients, etiology, defect size.
| Patient/gender | Age | Defect (cm) | Bone seat | Etiology | Infection before 1st stage |
|---|---|---|---|---|---|
| LD/M | 28 | 9 | Femur | Fracture | Yes |
| TR/M | 28 | 8 | Femur | Fracture | No |
| PI/F | 26 | 12 | Tibia | Fracture | No |
| BR/M | 41 | 7 | Femur | Fracture | No |
| GE/M | 31 | 9 | Femur | Fracture | Yes |
| CL/M | 31 | 9 | Femur | Aseptic non-union | No |
| FM/M | 35 | 11 | Femur | Septic non-union | Yes |
| LB/M | 27 | 9 | Femur | Fracture | No |
| Mean | 30,8 | 9,25 |
2.2. Surgical procedures
During the first stage the bony ends were excised and carefully prepared with a curette. The fragments were stabilized by a static locked nail (Fig. 1b and c). The nail diameter ranged from 10 to 12 mm. The length of the limb was adjusted on the contralateral limb. The polymethyl methacrylate (PMMA) gentamycin cement spacer was placed around the nail in a cylindrical manner so as to encase the bony ends for 2–3 cm (Fig. 1c). The volume to be filled was not calculated but the cement placed had a diameter greater than the one of bone segment. The tibia bone defect was secondary to an open fracture type IIIB of Gustilo-Anderson (GA) associated with skin defect. Careful debridement was done and the fracture stabilized by an external fixator. Antibiotic prophylaxis for 72 h was initiated with amoxicillin and clavulanic acid. The first stage was realized with an intramedullary nail at day 8 after a normal biological check of with blood cells, CRP, and sedimentation rate. The skin defect was managed by a neuro-sural flap at the same time. For the patient with the infected femoral pseudarthrosis a negative culture, a normal with blood cells count and CRP were obtained before the delivery of the cement.
Before the second stage, a biological check by blood count and normal CRP was required for all patients. This stage was systematically achieved about the end of the second month. After incision and opening of the induced membrane, removal of the cement spacer was removed without great difficulty around the nail. Cleaning of the accessible bone extremities was performed with the curette without decortication. The cancellous graft was taken from the iliac crest and mixed with phosphocalcic bone substitute not exceeding 1:3 ratio. The induced membrane was then closed, after graft placement, with a resorbable suture. The nail was not changed in any case. For the tibia defect an inter-tibio-fibular graft was not associated. Non-aspirating drain was done for 3 days. After wounds healing, the patients started a rehabilitation without bearing, with muscle maintenance, mobilization of joints above and below.
2.3. Patients follow-up
We assessed for each patient clinical, biological, and radiographic data, presence of infection, the delay of partial and total weight bearing, the delay of consolidation, and long-term complications. Total bearing was allowed before an x-ray showing consolidation on at least 3 corticals. All patients were operated on and followed by the same surgeon.
3. Results
The mean follow-up was 46.1 (35–72) months. Early bearing with support was allowed on average at the end of the 2 nd month. There was no sepsis before the second time. Total weight bearing without support was allowed at a mean of 5.5 months. Consolidation was obtained at 6.5 months for femurs (Fig. 2a). A complication of shortening of 2.35 cm on femur was noted in one patient (patient LB/M, Fig. 2b). The joints above and below mobility was complete before total bearing (Fig. 2c). He presented a limp on the walk at the last check. There was no malunion, amputation or persistent long-term infection, nor rupture of osteosynthesis material. The results are summarized in Table 2. The resumption of work was effective for patients after a mean of 24 months.
Fig. 2.
(A) AP X ray showing complete consolidation at 6 months. (B) shortening of 2.35 cm on femur. (C) Knee flexion of patient LB/M at 6 months.
Table 2.
Delay of consolidation, weight bearing, complications, follow-up.
| Patient/gender | Consolidation (m) | Total weight bearing (m) | Complications (m) | FU (m) |
|---|---|---|---|---|
| LD/M | 8 | 8 | Shortening 2,35 cm | 36 |
| TR/M | 8 | 3 | None | 72 |
| PI/F | 8,5 | 8 | None | 60 |
| BR/M | 4 | 4 | None | 38 |
| GE/M | 5 | 6 | None | 48 |
| CL/M | 7 | 6 | None | 42 |
| FM/M | 8 | 6 | None | 38 |
| LB/M | 6 | 3 | None | 35 |
| Mean | 6,8 | 5,5 | 46,1 |
FU = follow-up. m = month.
4. Discussion
The concepts of the induced membrane technique have been described for the treatment of bone defect secondary to osteomyelitis, tumor excision, post-traumatic bone defect, septic or non-septic pseudarthrosis.1 With these multiple etiologies of defect, all types of bone fixation are possible. As long as possible it should be: sufficiently rigid after the second stage to allow revascularization of the graft, dynamic later for graft corticalization phase.6 Initially, the preferential choice of external fixator allowed the surgeon to perform several iterative excisions because most cases were septic pseudarthrosis. This fixation was then maintained sometimes up to 14 months for the femur in order to obtain a consolidation and after allow a total weight bearing. This long external fixator does not confer a sufficiently rigid stabilization after the second stage and for great defect up to 20 cm. In addition to being poorly tolerated, it lengthens the delay of bearing and consolidation, and sometimes limiting access to skin flap.1,7 To overcome these shortcomings, several authors have modified the type of fixation.8 Apard et al.4 reported nailing at the first stage for 12 cases of post-traumatic segmental bone defect (8.7 cm) of tibia shaft, with 4-month bearing delay 4 Wong et al.9 reported excellent and uncomplicated results for 9 patients, using plate. Olesen et al.10 report the results of eight patients (4 nails and 4 plates) for a mean of 5 cm tibial bone defect, with consolidation delay of 218 days (7.1 months) and a bearing delay of 232 days. Bernstein et al.,8 in a series of 58 patients treated for post traumatic tibial BD, compared two groups of patients. One group had an “integrated fixator” combining the Illizarov external fixator with internal fixator by plate or centromedullary nail. The other group had a classic Illizarov external fixator. The consolidation delay in the first group was 7 months versus 11 months in the second group. But there was no significant difference in the difficulties or the number of complications.
In this present study femur was predominant, in contrary from other publications in which the tibia was the most common. In the first stage it is important to carefully clean and debride the bony extremities, to excise all the necrotic and devascularized tissues or the infected bone with a reamer (slow rotation).9 We took care to place the cement with gentamycin around the nail in a cylindrical way and to encase the bony ends on 2–3 cm. This trick allowed to have a continuous membrane with the periosteum.
Infection is the main complication feared in the induced membrane technique even more when associating an internal fixator.4 In the event of an open fracture or infection (patient PI/F), careful debridement and abundant washing was performed prior to nailing. It should be ensured that there is no infection by repeated debridement, successive negative bacteriological cultures, normal CBC and CRP before cementing.10 The IMT is not a technique for treating bone's infection.6 One of the mistakes is to think that the vascularization of the membrane allows to cure the infection. In addition, the action of gentamycin contained in the cement can overshadow a persistent infection after insufficient debridement. For this reason, it is recommended to use a cement without antibiotic.4,6
The nail is a foreign body which can lead to biofilm formation that is a source of sepsis or that can sustain an existing sepsis.10 In our series, the presence of the nail does not seem to increase the risk of infection. No evolutionary sepsis was detected before the second stage. Olesen does not report any early infection before the second stage and late during follow-up.10 The five long term infections reported by Apard et al. were persistent infections which were probably obscured by the action of gentamycin and also because of insufficient debridement before the first time.4
Apart from infection, few complications were reported when IMT associates nailing. It could be a stiffness,11 incomplete consolidation and reintervention for graft delivery,4 a nail break12 that occurs on an aseptic pseudarthrosis gone unnoticed. We observed a shortening of the limb (patient LB/M). This was due to earlier dynamization of nail for this patient. No correlation could be established between complications, extent of the defect and nailing.4,10
The presence of an intramedullary nail reduces the amount of cortico-cancellous graft required. This does not seem to affect consolidation in our series. Apard et al. and Olesen et al. come to the same conclusion.4,10 Nailing associated with IMT reduces the consolidation time compared to the external fixator.8,10,11 The immediate mobilization of the above and below joints and the early bearing allow: axial stimulation of the graft, to keep the alignment of the limb without any readjustments of assembly sometimes necessary with the external fixation. It seems to prevent plastic deformations observed with time in some cases (12]. The nail also allows to widen the indications to complex articular fractures (tibial pilon with diaphyseal extension) and metaphyseal fractures of the tibia.13 However, the presence of the intramedullary nail can mask a part of the continuity of the bone callus at the radiological evaluation.4 That may seem unpredictable because there is no correlation between the size of the defect and the delay of consolidation.10
5. Conclusion
The induced membrane technique in reconstruction of bone defects gives good results. This technique is facilitated by intramedullary nailing, which can be performed from the first time. This modification, especially with the femur, allows a better functional recovery (mobilization of the adjacent joints), preserves the axis of the limb, reduces the delay of weight bearing, reduces the volume of the graft needed without affecting the consolidation, limits the complications related to the use of the external fixator. It is crucial to eliminate any source of sepsis before placing the cement in order to minimize the risk of infection in the second time and in the long term. Although the modified IMT seems simple, it is essential to master the tips and tricks at the different stage. This short and retrospective study and further larger and prospective sample should be considered to confirm these observations and establish the principles and optimal conditions for consolidation.
Declaration of competing interest
Authors declare that they have no competing interest in relation with this manuscript.
Contributor Information
Gamal Ayouba, Email: gamal792003@yahoo.fr.
François Lemonne, Email: f.lemonne@ch-grasse.fr.
Noufanangue Kanfitine Kombate, Email: kludovick67@yahoo.fr.
Batarabadja Bakriga, Email: bakriga@yahoo.fr.
James Yaovi Edem, Email: nanoj@yahoo.fr.
Uzel André-Pierre Max, Email: maxuzel@hotmail.com.
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