Masquelet Induced Membrane Technique Research Articles

Combining non-vascularized fibula and cancellous graft in the masquelet technique: A promising approach to distal femur compound fracture management with large defects

IntroductionCompound fractures of the distal femur with large defects pose a significant challenge in management, with several options available, including external fixators, bone grafting, the Masquelet-induced membrane technique, and free vascularized fibular grafts. The Masquelet-induced membrane technique involves placing a cement spacer in the defect to create a biologically active membrane. In the second stage, the gold standard for filling the defect is an autologous cancellous bone graft of 1–2 mm in size. This study aims to examine the effects of using a non-vascularized fibula as a support combined with a cancellous graft in the Masquelet technique for treating compound fractures of the distal femur. MethodsThe study was conducted between December 2017 and December 2020 and included 11 patients who underwent the Masquelet technique. The procedure involved a lateral locked plate and an antibiotic-impregnated bone cement spacer, followed by a 20–30 mm longer ipsilateral fibula used as a strut graft. The remaining area was filled with cancellous bone from the iliac crest. The size of the defect, Time to the bony union, the average range of motion of the knee, and any complications are analysed. The final evaluation was done at 18 months using the Lower Extremity functional scale to assess functional outcomes. ResultsThe study included 11 patients (8 male and 3 female) with a mean age of 45.8 years. The average time to bony union was 6.6 months, and the average range of motion of the knee was 2.2° to 93.3 ° (0–110 °). No complications such as infection, non-union, or implant failure were observed. ConclusionThe Masquelet Technique combined with a fibular strut graft is a feasible solution for complex distal femur fractures with bone loss. The non-vascularized fibula graft provides both structural support and reduces the amount of cancellous bone graft needed, which results in earlier weight bearing and improved functional outcomes.

A review of the Masquelet technique in the treatment of lower limb critical-size bone defects.

The need for bone tissue to heal effectively is paramount given its role in the mechanical support of tissues. Bone has a very good natural healing potential in comparison with most other tissue types, largely regenerating to its pre-injury state in the vast majority of cases. Certain factors such as high energy trauma, tumour resection, revision surgery, developmental deformities and infection can lead to the formation of bone defects, where the intrinsic healing potential of bone is diminished owing to bone loss. Various approaches to resolving bone defects exist in current practice, each with their respective benefits and drawbacks. These include bone grafting, free tissue transfer, Ilizarov bone transport and the Masquelet induced membrane technique. This review focuses on evaluating the Masquelet technique, discussing its method and underlying mechanisms, the effectiveness of certain modifications, and its potential future directions.

Induced Membrane Technique is Effective for the Management of Acute Traumatic Bone Loss in Both Diaphyseal and Metaphyseal Lower Extremity Fractures.

To compare outcomes of Masquelet's induced membrane technique (IMT) in metaphyseal and diaphyseal fractures with acute bone loss. Retrospective cohort study Setting: Four Level 1 Academic Trauma CentersPatients/Participants: Patients acutely treated with IMT for traumatic lower extremity bone loss at four Level 1 trauma centers between 2010-2020. Operative treatment with placement of cement spacer within three weeks of initial injury followed by staged removal and bone grafting to the defect. Fracture union, infection, revision grafting, time to union, and amputation. 120 fractures met inclusion criteria, including 43 diaphyseal fractures (DIM) and 77 metaphyseal fractures (MIM). Demographic characteristics were not significantly different, except for age (DIM 34 years vs MIM 43 years, p< 0.001). Union after treatment with IMT was 89.2% overall. After controlling for age, this was not significantly different between DIM (41/43, 95.3%) and MIM (66/77, 85.7%) (p =0.13), nor was the rate of infection between groups. There was no difference in any secondary outcomes. The overall union rate in the current series of acute lower extremity fractures treated with induced membrane technique was 89%. There was no difference in successful union between patients with diaphyseal bone loss or metaphyseal bone loss treated with IMT. Similarly, there was no difference in patients with tibial or femoral bone loss treated with induced membrane. Defect size after debridement may be more prognostic for secondary operations rather than the limb segment involved or the degree of soft tissue injury. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Influence of the Immune Microenvironment Provided by Implanted Biomaterials on the Biological Properties of Masquelet-Induced Membranes in Rats: Metakaolin as an Alternative Spacer.

Macrophages play a key role in the inflammatory phase of wound repair and foreign body reactions-two important processes in the Masquelet-induced membrane technique for extremity reconstruction. The macrophage response depends largely on the nature of the biomaterials implanted. However, little is known about the influence of the macrophage microenvironment on the osteogenic properties of the induced membrane or subsequent bone regeneration. We used metakaolin, an immunogenic material, as an alternative spacer to standard polymethylmethacrylate (PMMA) in a Masquelet model in rats. Four weeks after implantation, the PMMA- and metakaolin-induced membranes were harvested, and their osteogenic properties and macrophage microenvironments were investigated by histology, immunohistochemistry, mass spectroscopy and gene expression analysis. The metakaolin spacer induced membranes with higher levels of two potent pro-osteogenic factors, transforming growth factor-β (TGF-β) and bone morphogenic protein-2 (BMP-2). These alternative membranes thus had greater osteogenic activity, which was accompanied by a significant expansion of the total macrophage population, including both the M1-like and M2-like subtypes. Microcomputed tomographic analysis showed that metakaolin-induced membranes supported bone regeneration more effectively than PMMA-induced membranes through better callus properties (+58%), although this difference was not significant. This study provides the first evidence of the influence of the immune microenvironment on the osteogenic properties of the induced membranes.

Filling the gap: a series of 3D-printed titanium truss cages for the management of large, lower limb bone defects in a developing country setting.

Large segmental long bone defects are notoriously difficult to manage. Treatment is resource-intensive due to the complexity, cost, and specialized skills required. Truss designs are known for their triangular shapes organized in web configurations. This allows for maximal mechanical strength, the least mass, and a lattice that can be filled with bone graft. Using a truss cage combined with contemporary internal fixation provides immediate stability for bone ingrowth and long-term potential union. The implant is designed using virtual 3D modelling of the patient's bone defect based on a CT scan. The truss cage can be used in a staged procedure combined with Masquelet's induced membrane technique. This study aims to review the outcomes of patient-specific, locally designed 3D titanium truss cages packed with cancellous autograft in treating segmental, long bone defects in the lower limb in a developing country setting. This retrospective series reviewed cases performed at various institutions between January 2019 and March 2022. Parameters assessed included patient demographics, size and location of the defect, time to clinical and radiological union and complications. Nine cases were included for review, with a mean age of 36years (range 19-52). Defects ranged from 60 to 205mm, and eight cases were staged procedures. Eight cases used intramedullary reamings as bone graft. Contemporary intramedullary nails were used for fixation in all cases. No peri- or post-operative complications occurred. All cases progressed to functional union. 3D-printed titanium truss cages combined with bone graft appear to be an effective treatment of large bone defects in the lower limb in a developing country setting in the short term. No complications were encountered, but longer follow-up is needed before definitive recommendations can be made. Level IV (retrospective case series).

Masquelet's induced membrane technique associated with Reamer Irrigation Aspiration grafting and intramedullary Nailing (MaRIAN) for chronic diaphyseal osteomyelitis of the lower limb

IntroductionMasquelet's induced membrane technique offers a definitive contribution to the treatment of diaphyseal osteomyelitis. To overcome its drawbacks while maintaining its principles, technical modifications have been proposed: antibiotic cement, femoral intramedullary autograft harvested by RIA (Reamer Irrigation Aspiration) and interlocking nails. Material and methodThis retrospective study gathered patients with chronic osteomyelitis of the femur or tibia. The first surgical stage consisted of bone resection in the healthy zone and use of a gentamicin cement spacer to fill the bone defect. The second stage consisted of the placement of a statically locked intramedullary nail associated with a bone autograft using the RIA technique. ResultsAmong this group of 12 men with diaphyseal osteomyelitis; 9 tibial and 2 femoral, and 1 knee nonunion, the mean bone defect was 7.3cm (±6.7). The mean time between the 2 stages was 2.7months (±3) with a mean antibiotic period of 3.25weeks (±3). There was a femoral diaphyseal fracture at the donor site, and a wrong trajectory intraoperatively during the RIA. Two patients with tibial nonunion presented with nail rupture without septic recurrence. A septic recurrence was healed by removal of the nail. At a minimum follow-up of 18months, with an average of 5years, consolidation was complete without infectious recurrence. Despite the statistical weakness related to the size of the cohort, the resumption of early weight bearing (OR=−7.68 95% CI [−13.33 to −2.08] (p=0.01)) and nail dynamization seemed to have an impact on the formation of complete consolidation (OR=−0.86 95% CI [−1.39 to −0.33] (p=0.007)). Discussion and conclusionThis short series, compared to the literature, demonstrated that the proposed technical modifications improved the overall management of this rare and challenging condition while maintaining the reliability of the original technique. Dynamization was also seen to be of particular interest. Level of evidenceIV, retrospective study.

Ilizarov bone transport combined with the Masquelet technique for bone defects of various etiologies (preliminary results).

BACKGROUNDThe Ilizarov bone transport (IBT) and the Masquelet induced membrane technique (IMT) have specific merits and shortcomings, but numerous studies have shown their efficacy in the management of extensive long-bone defects of various etiologies, including congenital deficiencies. Combining their strong benefits seems a promising strategy to enhance bone regeneration and reduce the risk of refractures in the management of post-traumatic and congenital defects and nonunion that failed to respond to other treatments.AIMTo combine IBT and IMT for the management of severe tibial defects and pseudarthrosis, and present preliminary results of this technological solution. METHODSSeven adults with post-traumatic tibial defects (subgroup A) and nine children (subgroup B) with congenital pseudarthrosis of the tibia (CPT) were treated with the combination of IMT and IBT after the failure of previous treatments. The mean number of previous surgeries was 2.0 ± 0.2 in subgroup A and 3.3 ± 0.7 in subgroup B. Step 1 included Ilizarov frame placement and spacer introduction into the defect to generate the induced membrane which remained in the interfragmental gap after spacer removal. Step 2 was an osteotomy and bone transport of the fragment through the tunnel in the induced membrane, its compression and docking for consolidation without grafting. The outcomes were retrospectively studied after a mean follow-up of 20.8 ± 2.7 mo in subgroup A and 25.3 ± 2.3 mo in subgroup B. RESULTSThe “true defect” after resection was 13.3 ± 1.7% in subgroup A and 31.0 ± 3.0% in subgroup B relative to the contralateral limb. Upon completion of treatment, defects were filled by 75.4 ± 10.6% and 34.6 ± 4.2%, respectively. Total duration of external fixation was 397 ± 9.2 and 270.1 ± 16.3 d, including spacer retention time of 42.4 ± 4.5 and 55.8 ± 6.6 d, in subgroups A and B, respectively. Bone infection was not observed. Postoperative complications were several cases of pin-tract infection and regenerate deformity in both subgroups. Ischemic regeneration was observed in two cases of subgroup B. Complications were corrected during the course of treatment. Bone union was achieved in all patients of subgroup A and in seven patients of subgroup B. One non-united CPT case was further treated with the Ilizarov compression method only and achieved union. After a follow-up period of two to three years, refractures occurred in four cases of united CPT. CONCLUSIONThe combination of IMT and IBT provides good outcomes in post-traumatic tibial defects after previous treatment failure but external fixation is longer due to spacer retention. Refractures may occur in severe CPT.

MicroRNA-149 suppresses osteogenic differentiation of mesenchymal stem cells via inhibition of AKT1-dependent Twist1 phosphorylation

Osteogenic differentiation is a vital process for growth, repair, and remodeling of bones. Accumulating evidence have suggested that microRNAs (miRNAs or miRs) play a crucial role in osteogenic differentiation of mesenchymal stem cells (MSCs). Hence, the current study set out to elucidate the role of miR-149 in osteogenic differentiation of MSCs and the underlying mechanism. First, rat models of bone differentiation were established using the Masquelet-induced membrane technique, and MSCs were isolated. The expression of miR-149 and AKT1 in the rats and cells was detected with RT-qPCR and western blot analysis. The relationships among miR-149, AKT1, and Twist1 were further predicted by online bioinformatics prediction and verified using dual luciferase reporter gene assay. Alteration of miR-149, AKT1, or Twist1 was performed to further explore their effect on osteogenic differentiation of MSCs. miR-149 was poorly expressed in the process of osteogenic differentiation of MSCs, while AKT1 was highly expressed. miR-149 negatively regulated the expression of AKT1, which in turn diminished the protein levels of Twist1 and promoted the phosphorylation levels of Twist1. Lastly, miR-149 acted as an inhibitor of osteogenic differentiation of MSCs, which could be reversed by AKT1. To sum up, miR-149 silencing promoted osteogenic differentiation of MSCs by enhancing Twist1 degradation through AKT1 upregulation, representing a new method for bone repair treatment.

Reconstruction of Large Bone Defects Using induced membrane Technique of Masquelet

Background: Management of large bone defects is a challenge for the surgeon and the patient as well, many functional and psychological disabilities results on and must be properly dealt with.Masquelet technique saves time, easily performed and can give good results in managing large bone defects.Methods: This is an interventional study in which 20 patients were treated using Masquelet technique for large intercalary bone defect. The recorded outcomes included bone union, residual deformity, infection, healing of soft tissues, returning to previous work, persistent pain, permanent joint contracture and patient satisfaction.Results: The period of follow up ranged from 2.2 to 4 years with a mean of 3.1 years. The bone defect ranged from 5 to13 cm with a mean of 7.5 cm. Fifteen patients out of 20 had an open fracture. Ilizarov was used in 13 cases, locked plates in 4 cases and an LRS in 3 cases. The interval between the 1st and the 2nd stages ranged from 42 to 84 days with an average of 56 days. 17 patients (85%) achieved bone union. The infection had relapsed in 4 patients, one of them with flap failure and 3 cases with insufficient debridement; one case was treated by another debridement using a free vascularized flap, 2 cases were shifted to bone transport technique and the last case ended with amputation. Conclusion: The Masquelet induced membrane technique was highly effective to achieve bone union especially in femoral cases.

Total Flavonoids of Rhizoma Drynariae Promotes Differentiation of Osteoblasts and Growth of Bone Graft in Induced Membrane Partly by Activating Wnt/β-Catenin Signaling Pathway.

Total flavonoids of Rhizoma drynariae (TFRD), a Chinese medicine, is widely used in the treatment of fracture, bone defect, osteoporosis and other orthopedic diseases, and has achieved good effects. Purpose of this trial was to explore efficacy of TFRD on bone graft’s mineralization and osteoblasts’ differentiation in Masquelet induced membrane technique in rats. Forty male Sprague-Dawley rats were randomly divided into high dose group (H-TFRD), middle dose group (M-TFRD), low dose group (L-TFRD) and control group (control). The critical size bone defect model of rats was established with 10 rats in each group. Polymethyl methacrylate (PMMA) spacer was implanted into the defect of right femur in rats. After the formation of the induced membrane, autogenous bone was implanted into the induced membrane. After 12 weeks of bone graft, bone tissues in the area of bone graft were examined by X-ray, Micro-CT, hematoxylin-eosin (HE) and Masson trichrome staining to evaluate the growth of the bone graft. The β-catenin, c-myc, COL1A1, BMP-2 and OPN in bone graft were quantitatively analyzed by Western blot and Immunohistostaining. Osteoblasts were cultured in the medium containing TFRD. Cell Counting Kit-8 (CCK-8) method, Alkaline phosphatase (ALP) and Alizarin Red S (ARS) staining, Western blot, RT-PCR and other methods were used to detect the effects of TFRD on the proliferation of osteoblasts and the regulation of Wnt/β-catenin signaling pathway. In vivo experiments showed that the growth and mineralization of bone graft in TFRD group was better. Moreover, the expression of Wnt/β-catenin and osteogenesis-related proteins in bone tissue of TFRD group was more than that in other groups. In vitro experiments indicated that osteoblasts proliferated faster, activity of ALP was higher, number of mineralized nodules and proteins related to osteogenesis were more in TFRD group. But blocking Wnt/β-catenin signaling pathway could limit these effects. Therefore, TFRD could promote mineralization of bone graft and differentiation of osteoblasts in a dose-dependent manner during growing period of the bone graft of induced membrane technique, which is partly related to the activation of Wnt/β-catenin signaling pathway.

Masquelet's induced membrane technique: Review of current concepts and future directions.

Masquelet's induced membrane technique (MIMT) is a relatively new, two-stage surgical procedure to reconstruct segmental bone defects. First performed by Dr. Masquelet in the mid-1980s, MIMT has shown great promise to revolutionize critical-sized bone defect repair and has several advantages over its alternative, distraction osteogenesis (DO). Also, its success in extremely challenging cases (defects > 15 cm) suggests that its study could lead to discovery of novel biological mechanisms that might be at play during segmental defect healing and fracture non-union. MIMT's advantages over DO have led to a world-wide increase in MIMT procedures over the past decades. However, MIMT often needs to be repeated and so the average initial success rate in adults lags significantly behind that of DO (86% vs 95%, respectively). The autologous foreign-body membrane created during the first stage by the immune system's response to a polymethyl methacrylatebone cement spacer is critical to supporting the morselized bone graft implanted in the second stage. However, the biological and/or physical mechanisms by which the membrane supports graft to bone union are unclear. This lack of knowledge makes refining MIMT and improving the success rates through technique improvements and patient selection a significant challenge and hinders wider adoption. In this review, current knowledge from basic, translational, and clinical studies is summarized. The dynamics of both stages under normal conditions as well as with drug or material perturbations is discussed along with perspectives on high-priority future research directions.

Masquelet's induced membrane technique for reconstruction of large extra-articular intercalary bone defect

Background: Intercalary bone defects are challenging for both surgeon and patient. The Masquelet's induced membrane technique saves bone consolidation time is less technically demanding than other techniques and achieves good results in the reconstruction of large extra-articular intercalary bone defects. Patients and Methods: This prospective study reviewed 60 patients treated with the induced membrane technique. Patients with femoral or tibial extra-articular intercalary bone defects ≥5 cm long, occurring either posttraumatically or after debridement of infected bone, were included in the study. Patients with bone defects <5 cm long were excluded from the study. The male-to-female ratio was 17:3. Patient age ranged from 10 to 50 years. Recorded outcomes included union, infection, residual deformity, soft-tissue healing, persistent pain, return to previous occupation, permanent joint contracture, and patient satisfaction. Results: Mean follow-up was 3.1 years (range, 2.2–4 years). Mean intercalary bone defect measured 7.5 cm (range, 5–13 cm) in length. Forty-five of 60 patients had open fractures. Thirty-nine underwent Ilizarov fixation, 12 with locked plates, and nine with a limb reconstruction system. The mean interval between the first and second stages was 56 days (range, 42–84 days). Bony union was achieved in 51 patients (85%). Twelve patients experienced relapsed infection during treatment, three because of flap failure, and nine because of inadequate debridement. Three were treated with repeat debridement and free vascularized flap after gastrocnemius flap, six underwent bone transport, and three required amputation. Conclusion: The Masquelet's induced membrane technique was highly effective in achieving the union of large femoral intercalary bone defects, with mixed results in the tibia.

Комбинированное применение несвободной костной пластики по Илизарову и техники Masquelet при реабилитации пациентов с приобретенными костными дефектами и ложными суставами

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.

Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad.

We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad. A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12months after IMT application. Sixteen patients with a mean age of 32.7years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6months. All failures were related to persistent infection or insufficient fixation stability in the second stage. This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.

Ankle arthrodesis using a modified Masquelet induced membrane technique for open ankle fracture with a substantial osteochondral defect: A case report of novel surgical technique

Reconstruction of a bone defect using the Masquelet induced membrane technique has been well described. However, there are few reports of arthrodesis using this technique. In this case report, we describe a modified Masquelet technique for ankle arthrodesis with nailing. The patient was a 32-year-old man who sustained an open fracture of the right ankle with a substantial osteochondral defect as a result of a fall. Immediately after the injury, a staged procedure using the Masquelet technique was planned. The bone defect was filled with bone cement in the acute stage, but replacement of the cement was needed 6 months after the injury because of a prolonged inflammatory reaction. Ten months after the injury, the bone cement was removed, and ankle arthrodesis was performed using an IM nail with a combination of autologous and artificial bone. As a modification of the Masquelet technique, the anterior surface of the transplant site was covered with a large but thin layer of cortical bone instead of suturing the incised membrane. At 1 year postoperatively, firm bony union was achieved and the implant was removed. At follow-up 3 years after his injury, the patient is able to walk, undertake physical work, and has no clinical signs of infection. Our experience suggests that a modified induced membrane technique may be useful when treating an open limb fracture with an extensive osteochondral defect where preservation of the joint is difficult and arthrodesis is considered.

Замещение дефекта большеберцовой кости фрагментом малоберцовой кости в условиях остеоиндуктивной мембраны

Introduction High-energy tibial fractures are challenging injuries to treat. Objective We report a case of a tibial gunshot fracture treated at several stages. Material and methods The fracture was first stabilized with external fixation device. The second stage aimed at the arrest of infection consisted of excision of necrotic tissues, placement of antibacterial spacer and repair of compromised soft tissues. Reconstructive surgery was produced at the third stage of treatment to address bone defect and provide consolidation. Results and discussion The Masquelet induced membrane technique, compression osteosynthesis with the Ilizarov frame and non-free autograft using fibular fragment facilitated recovery of supporting tibia functions within a relatively short period of time. Conclusion The combination of stimulating effects from different surgical techniques is useful to ensure a good outcome in a severe clinical case scenario.

Masquelet Induced Membrane Technique for The Surgical Treatment of Large Bone Defects: The Reasons for Successes and Failures

Masquelet Induced Membrane Technique for The Surgical Treatment of Large Bone Defects: The Reasons for Successes and Failures

Role of Beta Tri-calcium Phosphate-based Composite Ceramic as Bone-Graft Expander in Masquelet's-Induced Membrane Technique.

Background:Filling bone defect after debridement of infected nonunion is an orthopedic challenge. Since the volume of autologous bone graft available is limited, allograft, demineralized bone matrix, and calcium phosphate ceramic-based bone graft substitutes have come up as potential autograft expanders. This study was conducted to analyze the use of beta tri-calcium phosphate (B-TCP)-based composite ceramic as autologous bone-graft expander in the management of postinfective segmental gap nonunion of long bones managed with two-stage Masquelet's technique.Materials and Methods:42 consecutive patients with postinfective segmental long bone defects of 4–12 cm managed with Masquelet's-induced membrane technique, operated between February 2012 and June 2015, were included in this prospective case series. During the second stage bone-grafting procedure, iliac crest autograft alone or mixed with B-TCP granules (ratio not exceeding >1:1) was used along with appropriate internal-fixation. Bony union (defined clinicoradiologically as ability to painlessly bear weight on affected limb without support along with bridging of 3 cortices on X-rays) was evaluated.Results:Union was achieved in 80.9% patients (34/42) with index bone grafting. 100% union rate was achieved in patients where only autograft was used (15/15) and in nonsmoker femoral nonunion patients with the use of B-TCP (13/13). The use of B-TCP was associated with higher rate of nonunion in smokers (6/8, 75%) and in tibial nonunions (4/9, 55.5%). All, but one, of 8 patients with nonunion, united after the second-bone grafting procedure.Conclusion:B-TCP is an efficacious and safe autologous bone graft expander in Masquelet's two-stage management of post infective segmental gap nonunion of long bones. Patients should be counseled regarding increased risk of nonunion and need for repeat grafting with its use, especially if they are smokers or site of involvement is tibia.

Masquelet induced membrane technique for treatment of rat chronic osteomyelitis.

The application value of Masquelet induced membrane technique for the treatment of rat chronic osteomyelitis was explored. A total of 180 male Sprague-Dawley (SD) rats were randomly divided into sham operation group (control group), chronic osteomyelitis model group (model group) and Masquelet induced membrane therapy + chronic osteomyelitis model group (observation group); 60 rats in each group. A rat model of traumatic osteomyelitis was established using a modified blunt trauma method in model and observation group. All rats in observation group were treated with membrane induction technology while in the control group they were not. Postoperative complications, bone healing time and functional status of the affected limbs were recorded. After surgery, no obvious perioperative complications occurred in most of the rats, except that 5 rats experienced partial necrosis at the edge of the flap, and 3 experienced superficial infection around the incision site in the ilium. Primary bone healing was achieved in 50 rats with an average healing time of 15 weeks. Among them, 38 rats restored weight-bearing function after 20 weeks. Seven rats experienced infection after surgery, but complete bone healing was achieved after treatment with induced membrane technique again. Following treatment with induced membrane technique, the rat body weight, body temperature and the number of bacteria in the wound decreased over time. In conclusion, Masquelet induced membrane technique is effective for the treatment of large bone defects in rats after traumatic osteomyelitis. This technique significantly shortens the treatment cycle. The surgical procedure is simple, and the incidence of postoperative complications is low.

Curative effect of vancomycin-loaded calcium sulfate for one-stage treatment of chronic osteomyelitis

Objective To observe the effect of vancomycin-loaded calcium sulfate for one-stage treatment of chronic osteomyelitis. Methods A retrospective case series study was made on 26 patients with chronic osteomyelitis treated from January 2014 to April 2016. There were 23 males and 3 females, with a mean age of 35.8 years (range, 16-90 years). After focus debridement of osteomyelitis, the cavities were filled with vancomycin-loaded calcium sulfate and systemic antibiotics were used. Meanwhile, gentamicin was added to patients showing unclear pathogens. Three patients underwent flap transfer surgery simultaneously due to the inadequate soft tissue coverage. Wound healing, local redness and swelling, sinus recurrence, recovery of osteomyelitis and repair of bone defect were detected after operation. Results All patients were followed up for 6-30 months (mean, 19.5 months). Primary healing was achieved in all patients. One patient experienced wound exudate and was effectively managed by dressing change, one patient experienced inadequate local soft tissue coverage and was effectively managed by a second flap transfer surgery, and one patient remained wound unhealing after two surgeries and was cured by infected bone resection using the Masquelet induced membrane technique. Follow-up showed local bone defect was repaired in all patients without bone infection recurrence. Conclusions For patients with chronic osteomyelitis, one-stage surgery with vancomycin-loaded calcium sulfate can control infection with simultaneous repair of bone defect. Therefore, the procedure is a simple and effective method and worthy of clinical practice. Key words: Calcium sulfate; Vancomycin; Chronic steomyelitis