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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 125-128

Application of the induced membrane technique for treatment of diaphyseal bone defect secondary to osteomyelitis of ulna: A modified approach


1 Department of Orthopaedics and Pathology, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Orthopaedics, Raihan Institute of Medical Sciences, Kottayam, Kerala, India

Date of Submission29-Sep-2017
Date of Acceptance19-Oct-2017
Date of Web Publication8-Jan-2018

Correspondence Address:
Dr. Shishir Murugharaj Suranigi
Department of Orthopaedics, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_59_17

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  Abstract 

Induced membrane technique has gained wide popularity since it was first described by Alain C Masquelet in the year 2000. Before the advent of this procedure, the vascularized bone free transfer and the Ilizarov bone transport method were the only two salvage methods which produced satisfactory results in cases of wide long bone diaphyseal defects. The classical Masquelet technique described, involves the use of cancellous bone graft in a biological membrane, which is induced after placing polymethylmethacrylate (PMMA) cement that allows the formation of new bone. We report a case of a 21-year-old girl who had chronic osteomyelitis of ulna resulting in a segmental bony defect of 8 cm treated by modified Masquelet technique. Instead of using only the cancellous graft, we used a combination of fibular strut graft with iliac cancellous graft to reduce the period of morbidity and increase the chances of union. Radiographs done at 3 month-follow-up showed good integration of the graft on either end of the fibula strut graft. Patient had an excellent functional and radiological outcome. The modified-induced membrane technique for the treatment of posttraumatic osteomyelitis of the ulna is a simple, reliable method, with good early results.

Keywords: Chronic osteomyelitis, forearm fracture, induced membrane, Masquelet technique, polymethylmethacrylate cement


How to cite this article:
Suranigi SM, Babu AT, Pandian SR, Ramdas A, Najimudeen S. Application of the induced membrane technique for treatment of diaphyseal bone defect secondary to osteomyelitis of ulna: A modified approach. J Curr Res Sci Med 2017;3:125-8

How to cite this URL:
Suranigi SM, Babu AT, Pandian SR, Ramdas A, Najimudeen S. Application of the induced membrane technique for treatment of diaphyseal bone defect secondary to osteomyelitis of ulna: A modified approach. J Curr Res Sci Med [serial online] 2017 [cited 2018 Apr 25];3:125-8. Available from: http://www.jcrsmed.org/text.asp?2017/3/2/125/222425


  Introduction Top


Posttraumatic osteomyelitis with segmental bone loss is currently one of the greatest challenges faced by orthopedic surgeons. The osteomyelitis results in wide loss of bone due to radical debridement of sequestrum and surrounding unhealthy soft tissues. The ultimate goal of the treatment of posttraumatic osteomyelitis is to eradicate infection and also to restore the bony anatomy as early as possible with minimal functional damage. Stand-alone bone autografts generally do not integrate well if the gap is more than 4 cm to 5 cm. Most often this is due to graft resorption even in a good vascularized muscular envelope.[1] The vascularized bone free transfer and the Ilizarov bone transport method were the only two salvage methods which produced satisfactory results in cases of wide long bone diaphyseal defects before the Masquelet technique. This technique involves a two-stage procedure. In the first stage, radical debridement of dead bone and soft tissue is done with a soft-tissue repair by flaps when needed, and the insertion of a well-molded antibiotic-impregnated polymethylmethacrylate (PMMA) cement spacer into the bone defect. The second stage is performed 6–8 weeks later, when the infection is controlled and a definitive healing of soft tissue is achieved. The cement spacer is carefully removed without disturbing the surrounding membrane. The cavity is filled up by morcellized cancellous bone autograft.[2] Many surgeons have tried the use of bone substitutes, bone morphogenetic proteins and other additives to hasten the process of osteogenesis.[3]


  Case Report Top


A 21-year-old female sustained a road traffic accident in December 2014. She was treated for closed right-sided femur shaft fracture with intramedullary interlocking nail and closed right sided forearm both bones fracture with plating in another trauma center. She started to have pus discharge from the ulnar surgical site immediately after surgery. She presented to our institution 9 months postsurgery with complaints of pain, fever that was intermittent, low grade, and discharge from the ulnar surgical site. Pus was copious, blood tinged, continuously discharging from a single sinus located at the center of the surgical site. Blood investigations revealed elevated total white blood cell (WBC) count (17,500 cells/cumm), neutrophils (87%), erythrocyte sedimentation rate (ESR) (45 mm/h) and C-reactive protein (25 mg/L). Radiographs revealed non-union of ulna and united radius fracture. There were signs of osteolysis around the plate and screws at the ulna fracture site suggesting infected nonunion [Figure 1]a and [Figure 1]b. Pus culture revealed Staphylococcus aureus organism sensitive to most of Gram-positive organism sensitive antibiotics including vancomycin. It was decided to do a two-stage technique where the 1st stage was the removal of the implant, debridement of the dead bone and unhealthy tissues and placement of an antibiotic impregnated PMMA spacer. After the infection control was achieved, 2nd stage was commenced by using the induced membrane (Masquelet technique) and fibular strut graft with cancellous graft to achieve union.
Figure 1: (a) Immediate postoperative radiographs of both bones forearm fracture treated with plating. (b) Follow-up radiographs showing united radius fracture with osteolysis, periosteal reaction, and nonunion at the ulna fracture site. (c) Immediate postoperative radiographs showing fibular strut bone graft fixed with locking compression plate. (d) Radiographs at 6 months follow-up showing good integration of the graft with plate in situ

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After taking consent, sinusectomy and the implant exit was done using the previous incision. Intraoperatively, almost 7 cm of necrotic bone along with unhealthy granulation tissue was debrided. The sequestrum and surrounding unhealthy tissue were sent for culture, and the wound was extensively debrided and irrigated. Vancomycin (2 g powder) impregnated PMMA cement was molded into a cylindrical shape and placed in the area of bone loss [Figure 2]a. A suction drain was left in place and the wound was sutured in layers. To prevent collapse and abnormal movements at the fracture site, an external fixator with 2 schanz pins was applied. External fixator also helped the patient postoperatively to mobilize the elbow and wrist joint. The discharge subsequently reduced completely after the procedure [Figure 2]b. Radiographs at the end of 1 month showed no further bony destruction. Six weeks later, clinically, there were no signs of infection. Blood parameters such as total WBC count, ESR and C-reactive protein were normal. The radiograph showed no periosteal reaction or soft-tissue involvement. The patient had full range of motion at the elbow, forearm, and wrist joint. The patient was taken up for the 2nd stage where the external fixator and the cement spacer was removed. Intraoperatively, a thick, white membrane was noted around the PMMA cement mantle [Figure 2]c, [Figure 2]d, [Figure 2]e. The membrane was slit open, and the PMMA cement was extracted. Membrane was biopsied and sent for histopathological examination. Contra-lateral middle third fibula measuring 8 cm was excised percutaneously using 2 mini-incisions [Figure 2]f. Contra-lateral iliac cancellous bone graft was also harvested. The ulna bone edges was freshened with an oscillatory saw until healthy bleeding bone was identified, medullary canal was opened using a drill bit and the fibular strut graft was fashioned to match the defect [Figure 2]g. A 12 holed 3.5 mm titanium locking compression plate (LCP) was used to stabilize the bone, with 2 screws in the fibular graft, and 3 screws stabilizing the either end of the bone. Cancellous iliac bone graft was packed on either ends of the fibular strut graft within the membrane for better integration of the fibular strut graft and the membrane was sutured to either side of the LCP [Figure 2]h. Reduction and alignment were checked intraoperatively using the C-arm fluoroscopy.
Figure 2: Intraoperative images. (a) Cement spacer with external fixator after debridement and removal of the implant. (b) Clinical image of the healed sinus with external fixator in situ. (c and d) Induced membrane incised carefully to extract the polymethylmethacrylate cement spacer. (e) The induced membrane and 8 cm bone defect seen after removal of the spacer. (f) The harvested 8 cm fibula strut graft. (g) The fashioned fibular strut graft with plate in situ. (h) Cancellous graft placed on either end of the fibular strut graft within the membrane with locking compression plate

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Histological analysis of the membrane specimen showed maturating vascularized fibrous tissue with high concentration of calcium deposition [Figure 3].
Figure 3: Histological analysis. (a) H and E staining of the membrane specimen showing maturating vascularized fibrous tissue. (b) High-power view showing increased deposition of calcium in fibrovascular matrix

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Postoperatively, the wound healed well with no complications. Patient was started on elbow, forearm, wrist and hand mobilization exercises from day 2 postoperative period. At 3 months of follow-up, the patient had full range of motion at elbow, forearm, and wrist joints. No signs of infection were noted clinically or radiologically. All blood parameters remained normal. Radiographs done at 3 months follow-up showed good integration of the graft on either ends [Figure 1]c. Radiographs done at 6 months, 1 year, 2 years, and 2 ½ years follow-up showed complete integration of fibular strut graft [Figure 1]d. Patient remained asymptomatic with full functional range of motion [Figure 4].
Figure 4: Functional outcome. (a-d) Complete supination, pronation of forearm, extension and flexion of elbow, respectively

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  Discussion Top


The management of large segmental bone defects, especially in post osteomyelitic bone is a great challenge for orthopedic surgeons. Masquelet et al. described a procedure of induced membrane to promote the consolidation of a conventional cancellous bone autograft for reconstruction of long bone defects. In this technique, the induced membranes prevented the resorption of the graft resulting in good integration of the donor graft to the bone.[3] Masquelet and Begue proposed that this membrane prevents graft resorption as well as improves vascularization and results in corticalization of the graft. They described that, after the initial placement of the antibiotic-impregnated spacer, an interval of 6–8 weeks is needed for the formation of a biologically active membrane that is suitable for grafting. They found that this membrane was considered to induce bone union within 4 months regardless of the length of the bone defect. They further concluded that, although the induced membrane technique offers several theoretical and practical advantages, caution should be applied in the use of cancellous bone graft in defects exceeding 4 cm.[4] Contrary to this statement, many authors have achieved satisfactory results in massive bony defects up to 25 cm long. The PMMA spacer also helped in maintaining the defect and inhibited fibrous in-growth at the defect site.[5]

Masquelet et al.[3] reported that some of the patients required repeated bone grafts and that fracture occurred in four of the 35 cases after union, suggesting the poor quality of bone formation in some cases.

Experiments show that the induced membrane is rich in vascular endothelial growth factor, bone morphogenic protein 2, transforming growth factor beta1 and bone progenitor cells, so it has osteoinductive properties resulting in neobone formation. The membrane studied in our laboratory also demonstrated significantly higher fibrovascular proliferation with abundant calcium deposits.[6],[7]

Fibular grafts (strut or vascularized) being structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm have always been the choice for skeletal reconstruction by many surgeons in the past. The vascularized fibular graft is indicated in patients with large bone defects, exceeding 6 cm. In large segmental defects of the forearm (6 cm), we feel combining the fibular strut graft along with cancellous bone graft inside the induced membrane hastens the process of union and graft uptake compared to the usage of cancellous bone alone. The resultant bone is of the same width and quality as that of the surrounding bone. Fibula, having the similar anatomical structure as that of ulna can serve as an excellent donor for the diseased ulna. Compared with other bone restoring procedures, Masquelet technique has the advantages of easy to learn, few complications, low requirements, shorter bone-formation time, and wide application in any long bone of the body.[8],[9] Combination of sensitive antibiotic to the PMMA cement in the 1st stage also has the additional advantage of infection control.

With the development of tissue-engineered bone to induce osteogenesis using the induced membrane in animal models, scientists have successfully repaired a 7.2 cm segmental tibial defect with induced membrane and bone tissue engineering. After successful clinical trials in humans, this combination of induced membrane technique with tissue-engineered bone can have a wide range of application in clinical treatment of patients with large bone defects in years to come.[10] This concept could probably be extended to other tissue repair as well.


  Conclusion Top


The Masquelet technique provides a reasonable alternative for the challenging problem of significant bone loss in extremity reconstruction. Addition of cortical strut graft such as fibula significantly reduces the time for union and the time taken by cancellous bone to get converted to cortical bone. With the increasing popularity of the technique and its modifications by various surgeons, the specific indications and graft choices will become more clearer in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dinh P, Hutchinson BK, Zalavras C, Stevanovic MV. Reconstruction of osteomyelitis defects. Semin Plast Surg 2009;23:108-18.  Back to cited text no. 1
    
2.
Apard T, Bigorre N, Cronier P, Duteille F, Bizot P, Massin P, et al. Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing. Orthop Traumatol Surg Res 2010;96:549-53.  Back to cited text no. 2
    
3.
Masquelet AC, Fitoussi F, Begue T, Muller GP. Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet 2000;45:346-53.  Back to cited text no. 3
    
4.
Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010;41:27-37.  Back to cited text no. 4
    
5.
Woon CY, Chong KW, Wong MK. Induced membranes – A staged technique of bone-grafting for segmental bone loss: A report of two cases and a literature review. J Bone Joint Surg Am 2010;92:196-201.  Back to cited text no. 5
    
6.
Aho OM, Lehenkari P, Ristiniemi J, Lehtonen S, Risteli J, Leskelä HV, et al. The mechanism of action of induced membranes in bone repair. J Bone Joint Surg Am 2013;95:597-604.  Back to cited text no. 6
    
7.
Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res 2004;22:73-9.  Back to cited text no. 7
    
8.
Micev AJ, Kalainov DM, Soneru AP. Masquelet technique for treatment of segmental bone loss in the upper extremity. J Hand Surg Am 2015;40:593-8.  Back to cited text no. 8
    
9.
Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R. Masquelet technique for the treatment of bone defects: Tips-tricks and future directions. Injury 2011;42:591-8.  Back to cited text no. 9
    
10.
Viateau V, Bensidhoum M, Guillemin G, Petite H, Hannouche D, Anagnostou F, et al. Use of the induced membrane technique for bone tissue engineering purposes: Animal studies. Orthop Clin North Am 2010;41:49-56.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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