Use of fibular graft in Masquelet technique in osteomyelitis of long bones- a novel modification in the technique

INTRODUCTION

Osteomyelitis (Figure 1) is a form of inflammation involving the bone tissue or marrow caused by a pathogenic organism.¹ Chronic osteomyelitis mainly occurs in the long bones. A two-stage surgical method for the treatment of bone defects has been reported by Masquelet in recent years, which is called the induced membrane technique.² This induced membrane technique has been used for the treatment of osteomyelitis.³ If the gap is more than 4–5 cm, stand-alone bone autografts generally do not integrate well. Most often this is due to graft resorption even in a good muscular envelope.⁴

So, in this study, to reduce the period of morbidity and increase the chances of union and to see the clinical efficiency of this modified technique, we used a combination of fibular strut graft (Figure 6) with iliac cancellous graft instead of using only the cancellous graft.

In this study, we aimed to determine the clinical efficiency of the modified Masquelet technique for bone loss due to osteomyelitis in the long bones.

METHODS

This prospective study was conducted in our tertiary center Shri Vasantrao Naik medical college and hospital, Yavatmal between August 2016 and September 2020 and consisted of 10 patients (6 males and 4 female). All patients were treated using the induced membrane technique. Our study included patient from 20 to 56 age group and with chronic osteomyelitis. Acute osteomyelitis and polytrauma patients were excluded.

In the first stage, antibiotic-loaded PMMA cement (Figure 2) was used to fill the bone defects (Figure 3) after radical debridement. In the second stage (Figure 7), bone grafts were implanted to rebuild the bone defects. After 6-8 weeks, infection assessment was performed before grafting. The cement was removed, the wound washed, and a graft of appropriate size was cut. We used a fibular strut graft along with cancellous bone graft. The membrane was then grafted and sutured.

The patients underwent follow-up at 3, 6, 12, and 24 months. Assessment of functional outcome by range of movement of internal rotation and abduction was done and also assessment by radiographic healing was done with evidence of infection if any.

RESULTS

Our study included 10 patients, of whom six were males and 4 females. The mean age of the patients was 34 years (range: 20-54 years). The mean duration of bone infection was 4 months (3 to 5 months). The average follow-up period was 16 months (range: 12-24 months).

Satisfactory range of movement was achieved with average internal rotation of 5 degrees, 10 degrees, 15 degrees and 20 degrees at 3 months, 6 months, 12 months and 24 months and average abduction of 45 degrees, 60 degrees, 75 degrees and 100 degrees at 3 months, 6 months, 12 months and 24 months.

Radiographic evidence of bone union was seen in 6 months (3 to 9 months). There was no recurrence of infection in any case.

60 percent patients were males.

Most patient were of the age group 32-43.

Mean duration of infection was 4 months.

Post operative satisfactory internal rotation of 5 degrees, 10 degrees, 15 degrees and 20 degrees was achieved on an average with each follow up.

Post operative satisfactory abduction of 45 degrees, 60 degrees, 75 degrees and 100 degrees was achieved on an average with each follow up.

DISCUSSION

The lack of a generally accepted treatment method for chronic osteomyelitis is a serious problem for orthopedicians. Ilizarov technique, one stage bone grafting and vascularised fibula graft are some of the classic techniques for chronic osteomyelitis, but these are often associated with long-term recurrence rates and high complications.^5-7 For the reconstruction of long bone defects, a procedure for induced membrane formation was described by Masquelet et al to promote the consolidation of conventional cancellous bone autografts. In this technique, there was good integration of the donor graft into the bone, as the induced membranes prevented the resorption of the graft. In his study of 15 patients, El-Alfy obtained satisfactory results when treated with a free nonvascularized fibula graft. The average time to bone union was 7 months, which was approximately the same as that in our study (6 months).⁸ In the case series of Woon et al and Scholz et al, infected non-union was the etiology.^9,10 In the study done by Woon et al,1 case united after 11.5 months, may be due to using corticocancellous graft which has less healing properties than pure cancellous graft and union occurred after 4.5 months (range: 2.8-5.6 months) in the study done by Scholz et al.^9,10

Masquelet technique has the advantages of easy learning, lesser complications, shorter bone union time, and wide application in any long bone when compared with other bone restoring procedures.^7,11

CONCLUSION

The induced membrane technique is a reliable method for the treatment of long-bone osteomyelitis. The addition of a fibular strut graft significantly reduced the time taken by cancellous bone to be converted to cortical bone and the time for union. There was also a lower incidence of infection, but more studies are needed to support this finding.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Agarwal A, Aggarwal AN. Bone and joint infections in children: acute hematogenous osteomyelitis. Indian J Pediatr. 2016;83(8):817-24.
2. 2. Masquelet AC, Fitoussi F, Begue T, Muller GP. Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chirurg Plast Esthet. 2000;45(3):346-53.
3. 3. Canavese F, Corradin M, Khan A, Mansour M, Rousset M, Samba A. Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute. Eur J Orthopaed Surg Traumatol. 2017;27:221-8.
4. 4. Dinh P, Hutchinson BK, Zalavras C, Stevanovic MV. Reconstruction of osteomyelitis defects. Semin Plast Surg. 2009;23:108-18.
5. 5. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am. 1995;77(6):835-46.
6. 6. Gao YS, Ai ZS, Yu XW, Sheng JG, Jin DX, Chen SB, et al. Free vascularised fibular grafting combined with a locking plate for massive bone defects in the lower limbs: a retrospective analysis of fibular hypertrophy in 18 cases. Injury. 2012;43(7):1090-5.
7. 7. 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(6):591-8.
8. 8. El-Alfy B, Abulsaad M, Abdelnaby WL. A free nonvascularized fibular graft in the induced membrane technique is used to manage post-traumatic bone defects. Eur J Orthop Surg Traumatol. 2018;28:1191-7.
9. 9. 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. JBJS. 2010;92(1):196-201.
10. 10. Scholz AO, Gehrmann S, Glombitza M, Kaufmann RA, Bostelmann R, Flohe S, et al. Reconstruction of septic diaphyseal bone defects with the induced membrane technique. Injury. 2015;46:S121-4.
11. 11. Micev AJ, Kalainov DM, Soneru AP. Masquelet technique for the treatment of segmental bone loss in the upper extremities. J Hand Surg Am. 2015;40:593-8.