Abstract
The healing of critical sized segmental defects is an ongoing clinical problem. No method has achieved pre-eminence. The Masquelet technique is a relatively new innovation involving the induction of a fibrous tissue membrane around the bone defect site taking advantage of the body’s foreign body reaction to the presence of a polymethylmethacrylate (PMMA) spacer. The aim of this study was to investigate the properties and characteristics of this induced membrane and its effectiveness when used in conjunction with allograft or an allograft/autograft mix as filler materials in an ovine critical sized defect model. The resultant induced membrane was found to be effective in containing the graft materials in situ. It was demonstrated to be an organised pseudosynovial membrane which expressed bone morphogenic protein 2 (BMP2), transforming growth factor- beta (TGFβ), vascular endothelial growth factor (VEGF), von Willerbrand factor (vWF), interleukin 6 (IL-6) and interleukin 8 (IL-8). While more new bone growth was evident in the test groups compared to the controls animals at 12 weeks, the volumes were not statistically different and no defects were fully bridged. Of the two graft material groups, the allograft/autograft mix was shown to have a more rapid graft resorption rate than the allograft only group. While the Masquelet technique proved effective in producing a membrane to enclose graft materials, its ability to assist in the healing of critical sized segmental defects when compared to empty controls remained inconclusive.
Highlights
The treatment of critical sized segmental defects is an ongoing clinical problem
The large volumes of graft material required to fill critical sized segmental defects leads to an increase in the incidence of co-morbidities associated with the harvesting of large amounts of autograft, its exclusive use in these scenarios can often outweigh the benefits
Materials used to help decrease the reliance on autograft are mostly osteoconductive, they can be combined with proteins such as bone morphogenic proteins (BMPs) [4, 5] or vascular endothelial growth factor (VEGF) [6], to bestow some osteoinductive properties to these materials as well
Summary
The treatment of critical sized segmental defects is an ongoing clinical problem. The delayed unions and non-unions that can occur as a result of poor patient healing response to stabilisation and grafting techniques currently in use, places extra demand on the patient and surgeon, and on the costs incurred in the hospital system through increased lengths of hospital stays and reoperations [1, 2]. As the incidence of segmental bone loss through trauma increases, for example in motor vehicle accidents or injuries acquired as a result of the many ongoing global conflicts, so does the need to find suitable and effective treatments for these situations. Autograft is considered the gold standard void filler for treating bone loss during fracture fixation; it provides osteoconductive, osteoinductive and osteogenic factors at the site of injury [3]. The large volumes of graft material required to fill critical sized segmental defects leads to an increase in the incidence of co-morbidities associated with the harvesting of large amounts of autograft, its exclusive use in these scenarios can often outweigh the benefits. Blood clots have been proposed and used as a method of forming a mouldable cohesive material for use across defects with the added benefit of providing some healing tissue factors, mixed results have been achieved [16, 17]
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