Masquelet Technique: Effects of Vancomycin Concentration on Quality of the Induced Membrane

The induced membrane technique was initially described by Masquelet et al. in 1986 as a treatment for tibia nonunion; then, it became one of the established methods in the management of bone defects. Several changes have been made to this technique and have been used in different contexts and different methodologies. We present the case of a 16-year-old girl admitted to our department for a polytrauma after a motorcycle accident. She presented a Gustilo III-A open fracture of the right femoral shaft with a large bone defect of 8 centimeters that we treated with a modified Masquelet technique. In the first stage, an Open Reduction and Internal Fixation of the fracture was made using a 4,5 mm Dynamic Compression Plate and a PMMA cement was inserted at the bone defect area. The second stage was done after 11 weeks, and the defect area was filled exclusively with bone allograft from a bone bank. Complete bony union was seen at 60 weeks of follow-up. After the removal of the implants by another surgeon, the patient presented an atraumatic fracture of the neoformed bone that we treated with intramedullary femoral nailing associated with a local autograft using reaming debris. A complete bony union was achieved after 12 weeks with a complete range of motion of the hip and knee. The stability given to the fracture is essential because it influences the quality of the induced membrane and Masquelet has recommended high initial fixation rigidity to promote incorporation of the graft. It is recommended to delay the second stage of this technique after 8 weeks, especially in femoral reconstruction, to optimize the quality of the induced membrane. Several studies used a modified induced membrane technique to recreate a traumatic large bone defect, and all of them used an autologous bone graft alone or an enriched bone graft. In this case, the use of allograft exclusively seems to be as successful as an autologous or enriched bone graft. Now, with the advent of bone banks, it is possible to get an unlimited amount of allograft, so additional research and large studies are necessary before giving recommendations.

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From two stages to one: acceleration of the induced membrane (Masquelet) technique using human acellular dermis for the treatment of non-infectious large bone defects

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-019-01296-x ◽

2020 ◽

Vol 46 (2) ◽

pp. 317-327 ◽

Cited By ~ 6

Author(s):

René Danilo Verboket ◽

Maximilian Leiblein ◽

Maren Janko ◽

Alexander Schaible ◽

Jan Claas Brune ◽

...

Keyword(s):

Bone Defects ◽

Induced Membrane ◽

Acellular Dermis ◽

Masquelet Technique ◽

Two Stages ◽

Large Bone ◽

Large Bone Defects

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Reconstruction of massive tibial defect caused by osteomyelitis using induced membrane followed by trifocal bone transport technique: a retrospective study and our experience

BMC Surgery ◽

10.1186/s12893-021-01421-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yimurang Hamiti ◽

Maimaiaili Yushan ◽

Cheng Lu ◽

Aihemaitijiang Yusufu

Keyword(s):

Clinical Outcomes ◽

Operation Time ◽

Bone Transport ◽

Fixation Index ◽

Induced Membrane ◽

Tibial Defect ◽

Previous Operation ◽

Masquelet Technique ◽

Transport Technique

Abstract Objective To evaluate clinical outcomes of the application of induced membrane followed by trifocal bone transport technique in the treatment of massive tibial defect caused by osteomyelitis. Method A total of 18 eligible patients with tibial defect > 6 cm caused by osteomyelitis who were admitted to our institution from January 2010 to January 2016 and treated by induced membrane followed by trifocal bone transport technique. There were 12 male and 6 females with an average age of 40.4 years old. A detailed demographic data (age, sex, etiology, previous operation time, defect size and location, interval from Masquelet technique to trifocal bone transport technique, external fixation index (EFI), duration of regenerate consolidation and docking union) were collected, bone and functional outcomes were evaluated by Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during and in the period of follow up were recorded and evaluated by Paley classification at a minimum follow-up of 2 years. Results The etiology include posttraumatic osteomyelitis in 13 cases and primary osteomyelitis in 5 cases. An average of previous operation time was 3.4 times. Mean tibial defect after radical debridement was 6.8 cm. An average interval duration from formation of induced membrane to trifocal bone transport was 4.8 weeks. An average of EFI was 37.1 days/cm, the duration of regenerate consolidation and docking union were 124.7 days and 186.4 days, respectively. An average time of follow-up after removal of external fixator was 28.5 month without recurrence of osteomyelitis. The bony outcome was excellent in 6 cases, good in 8 cases, fair in 3 cases and poor in 1 case, and functional outcome was excellent in 4 cases, good in 10 cases, fair in 2 cases and poor in 2 cases. The most common complication was pin tract infection which occurred in 15 cases and there were no major complications such as nerve or vascular injury. Conclusion Massive tibial defect caused by osteomyelitis can be successfully treated first stage using induced membrane followed by second stage using trifocal bone transport technique, which is an effective method in terms of radical elimination of osteomyelitis with expected clinical outcomes.

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Combined use of the Ilizarov non-free bone plasty and Masquelet technique in patients with acquired bone defects and pseudarthrosis

Genij Ortopedii ◽

10.18019/1028-4427-2020-26-4-532-538 ◽

2020 ◽

Vol 26 (4) ◽

pp. 532-538

Author(s):

D.Yu. Borzunov ◽

◽

D.S. Mokhovikov ◽

S.N. Kolchin ◽

E.N. Gorbach ◽

...

Keyword(s):

Bone Grafting ◽

Soft Tissues ◽

Bone Defects ◽

Bone Transport ◽

Long Bone ◽

Cement Spacer ◽

Technical Problems ◽

Induced Membrane ◽

Masquelet Technique ◽

Membrane Technique

Introduction The Masquelet induced membrane technique is effective in the management of acquired heterogeneous long bone defects and pseudarthrosis. The combination of the Masquelet technology and Ilizarov non-free bone grafting seems promising and reduces the risks of recurrence at long-term in patients with congenital pseudarthrosis. Purpose Presentation of new technological solutions that allow combining the advantages of the Ilizarov bone transport and Masquelet bone grafting in patients with acquired bone defects. Materials and methods Retrospective assessment of the results of bone reconstruction in 10 patients who were treated by a combination of Ilizarov and Masquelet bone grafting technologies to repair long bone defects after failures of previous treatment. Fragments of the biomembrane formed around the cement spacer temporarily replacing the tibial gap after resection bone defect or pseudarthrosis were examined in all patients. The studies were carried out using a Reichard sledge microtome, an AxioScope stereomicroscope and an AxioCam ICc 5 digital camera, a JSM- 840 scanning electron microscope and an INCA-200 Energy X-ray electron probe microanalyzer. Results and discussion The combined Masquelet technique and Ilizarov non-free bone plasty provide the conditions that are favorable for reparative processes of the transported fragments. After removal of the spacer, there is a tunnel formed in the interfragmental gap, the walls of which are made of the induced membrane. Bone transport is carried out without technical problems through the compromised tissues which are debrided at the time of distraction initiation, outside the scars. At the same time, there are low risks of inflammation around the transosseous elements; there is no danger of cutting and perforation of soft tissues by transported fragments. Conclusions Complete organotypic rearrangement of the distraction regenerate with the use of Ilizarov non-free bone plasty and the Masquelet technique excludes the possibility of deformities or fractures at the level of newly formed bone areas. Active distraction histogenesis ensures the closure of soft tissue defects without additional reconstructive plastic interventions. The revealed dependence of the induced membrane blood supply on the method of treatment previously used might be a criterion for predicting the treatment outcome in patients with acquired bone defects and pseudarthrosis.

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The deleterious relationship of Pseudomonas aeruginosa and Induced Membranes in infected non-union treatment

International Journal of Research in Pharmaceutical Sciences ◽

10.26452/ijrps.v12i1.4032 ◽

2021 ◽

Vol 12 (1) ◽

pp. 388-391

Author(s):

Thiyagarajan U ◽

Senthil Loganathan ◽

Raghavendar ◽

Pradeep P

Keyword(s):

Pseudomonas Aeruginosa ◽

Bone Graft ◽

Bone Defect ◽

Bone Defects ◽

Reconstructive Procedures ◽

Induced Membrane ◽

Non Union ◽

Masquelet Technique ◽

Slime Layer ◽

Pseudomonas Infection

The Masquelet technique was originally described for the treatment of an infected non-union with an extensive bone defect where a staged protocol was needed to first eliminate an infection then secondarily bone graft a defect. Though this is a versatile technique, certain limitations/ complications must be recognized. The study was done between 2012 to 2019 at SRIHER university. 19 patients in whom the Masquelet technique has failed is taken into study. 17 male and two females, with a mean age of 31 years (range of 13 yrs. – 51 yrs.) with a mean follow up of 12 months. The 19 patients who presented with Pseudomonas aeruginosa infected non-union of the tibia and femur with bone defects underwent the Masquelet technique. All patients failed to form adequate induced membrane at the non-union site. Infected non-union with a bone defect is difficult to treat. Bone defects of 2cms can be treated by cancellous bone grafting. Defects more than 4-5cms will require specialized reconstructive procedures to prevent amputation. The two common techniques used are Ilizarov technique with bone transport and bone graft into an induced membrane as described by Masquelet. This study shows a high failure rate of the Masquelet technique with Pseudomonas infection. The most difficult issue faced by the surgeon in treating P. aeruginosa is its ability to develop resistance to multiple classes of antibiotics during the course of treating the patient. Masquelet technique is used extensively for the treatment of infective non-union. Pseudomonas secretes a slime layer that may lead to a weak or deficient formation of the induced membrane. And the elution of antibiotics may not be adequate for intramedullary osteomyelitis with pseudomonas growth. This limits the Masquelet technique in the management of infected non-union with pseudomonas infection.

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Osteoclasts and their precursors are present in the induced-membrane during bone reconstruction using the Masquelet technique

Journal of Tissue Engineering and Regenerative Medicine ◽

10.1002/term.1921 ◽

2014 ◽

Vol 11 (2) ◽

pp. 382-389 ◽

Cited By ~ 33

Author(s):

Richard Gouron ◽

Laurent Petit ◽

Cédric Boudot ◽

Isabelle Six ◽

Michel Brazier ◽

...

Keyword(s):

Bone Reconstruction ◽

Induced Membrane ◽

Masquelet Technique

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Immunohistochemical Analysis Revealed the Expression of Bone Morphogenetic Proteins-4, 6, 7, and 9 in Human Induced Membrane Samples Treated With the Masquelet Technique

10.21203/rs.3.rs-882634/v1 ◽

2021 ◽

Author(s):

Takahiro Niikura ◽

Takahiro Oda ◽

Naoe Jimbo ◽

Masato Komatsu ◽

Keisuke Oe ◽

...

Keyword(s):

Bone Tissue ◽

Bone Morphogenetic Proteins ◽

Immunohistochemical Analysis ◽

Bone Defects ◽

Positive Control ◽

Cement Spacer ◽

Induced Membrane ◽

Masquelet Technique ◽

Human Bone Tissue ◽

Large Bone

Abstract BackgroundInduced membrane (IM) is the key component of Masquelet reconstruction surgery for the treatment of bone defects. It is formed around the cement spacer and is known to secrete growth factors and osteoinductive factors. However, information on the presence of osteoinductive factors in IM is not enough in the literature. The purpose of this study was to investigate the existence of bone morphogenetic proteins (BMPs) in the IM harvested from patients during the treatment of bone defects using the Masquelet technique.MethodsWe included six patients whose bone defects were treated using the Masquelet technique. The affected bone was the femur in three patients and the tibia in three patients. During the second-stage surgery, 1-cm2 pieces of IM were harvested. Histological sections of IM were immunostained with anti-BMP-4, 6, 7, and 9 antibodies. Human bone tissue served as the positive control.ResultsThe existence of BMP-4, 6, 7, and 9 was observed in all IM samples. Further, immunolocalization of BMP-4, 6, 7, and 9 was observed in blood vessels and fibroblasts of all IM samples. Immunolocalization of BMP-4, 6, 7, and 9 was also observed in bone tissue within the IM in one sample, in which osteogenesis inside the IM was observed.ConclusionsThis study revealed that osteoinductive factors BMP-4, 6, 7, and 9 were present in the IM harvested from patients. This helps explain how the Masquelet technique effectively contributes to the healing of large bone defects. It may thus be possible for surgeons to omit the addition of BMPs to bone grafts give the endogenous secretion of BMPs from the IM.Trial registrationNot applicable.

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Immunohistochemical analysis revealed the expression of bone morphogenetic proteins-4, 6, 7, and 9 in human induced membrane samples treated with the Masquelet technique

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-022-02922-y ◽

2022 ◽

Vol 17 (1) ◽

Author(s):

Takahiro Niikura ◽

Takahiro Oda ◽

Naoe Jimbo ◽

Masato Komatsu ◽

Keisuke Oe ◽

...

Keyword(s):

Bone Tissue ◽

Bone Morphogenetic Proteins ◽

Immunohistochemical Analysis ◽

Bone Defects ◽

Positive Control ◽

Cement Spacer ◽

Induced Membrane ◽

Masquelet Technique ◽

Human Bone Tissue ◽

Large Bone

Abstract Background Induced membrane (IM) is the key component of Masquelet reconstruction surgery for the treatment of bone defects. IM is formed around the cement spacer and is known to secrete growth factors and osteoinductive factors. However, there is limited evidence available concerning the presence of osteoinductive factors in IM. This study aimed to investigate the existence of bone morphogenetic proteins (BMPs) in IM harvested from patients during the treatment of bone defects using the Masquelet technique. Methods This study involved six patients whose bone defects had been treated using the Masquelet technique. The affected sites were the femur (n = 3) and the tibia (n = 3). During the second-stage surgery, 1 cm2 pieces of IM were harvested. Histological sections of IM were immunostained with anti-BMP-4, 6, 7, and 9 antibodies. Human bone tissue served as the positive control. Results The presence of BMP-4, 6, 7, and 9 was observed in all IM samples. Further, immunolocalization of BMP-4, 6, 7, and 9 was observed in blood vessels and fibroblasts in all IM samples. Immunolocalization of BMP-4, 6, 7, and 9 was also observed in bone tissue within the IM in one sample, in which osteogenesis inside the IM was observed. Conclusions This study showed that osteoinductive factors BMP-4, 6, 7, and 9 were present in the IM harvested from patients, providing evidence indicating that the Masquelet technique effectively contributes to healing large bone defects. Therefore, it may be possible for surgeons to omit the addition of BMPs to bone grafts, given the endogenous secretion of BMPs from the IM.

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