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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 44-48

Current overview on masquelet technique


1 Department of Orthopaedics, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
2 Department of Orthopaedics, ESIC Medical College, Hyderabad, Telangana, India

Date of Submission05-Dec-2021
Date of Acceptance07-Dec-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Srinivas Kasha
Krishna Institute of Medical Sciences, Secunderabad - 500 003, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_30_21

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  Abstract 


Masquelet technique or induced membrane technique has gained wide popularity and is now widely accepted as a simple and effective technique for the reconstruction of segmental bone defects. The technique is founded on the concept that the enclosed foreign body induces a tissue response, which leads to the formation of a surrounding biological active membrane termed as “induced membrane.” The technique was initially described for bone loss resulting from septic nonunion of the leg, and it has been extended to all long bone segments, including the clavicle, whatever may be the etiology of the bone defect. In this review, we describe the current overview of the Masquelet technique over the last decade.

Keywords: Induced membrane technique, Masquelet technique – overview, modifications of Masquelet technique


How to cite this article:
Kasha S, Yalamanchili RK. Current overview on masquelet technique. J Orthop Assoc South Indian States 2021;18:44-8

How to cite this URL:
Kasha S, Yalamanchili RK. Current overview on masquelet technique. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 May 26];18:44-8. Available from: https://www.joasis.org/text.asp?2021/18/2/44/336658




  Introduction Top


Masquelet technique or induced membrane technique was first performed by a French surgeon – Alan Masquelet, in 1986.[1] Although the Masquelet technique has been used for more than 30 years, it has recently gained popularity and is now widely accepted as a simple and effective technique for the reconstruction of segmental bone defects. The technique is founded on the concept that the enclosed foreign body induces a tissue response, which leads to the formation of a surrounding biological active membrane termed as “induced membrane.”[2] The induced membrane encapsulating thin fibrous membrane is made of type 1 collagen-heavy matrix with fibroblastic cells and contains high concentrations of growth and osteogenic factors that help for tissue regeneration.[3],[4]

The technique was initially described for bone loss resulting from septic nonunion of the leg, and it has been extended to all long bone segments, including the clavicle, whatever may be the etiology of the bone defect.[5] It is also widely used in the reconstruction of bone defects resulting after excision or curettage of pathology in pseudoarthrosis, bone tumors, arthrodesis of joints, and recalcitrant nonunions without bone loss.[6] In this review, we describe the current overview of the Masquelet technique over the last decade.


  Technique Top


The technique primarily comprises two surgical stages staggered within 6–8-week duration. If the infection prevails at the time of bone grafting in Stage 2, Stage 1 is always repeated, i.e.,– redribedement and reimplantation of cement spacer. Hence, it is better described as two or more stages depending on the control of infection after Stage 1 surgery.[1],[2],[3]

First stage

In the first stage, a cement spacer is placed into the bone defect after thorough debridement of bone and surrounding soft tissues. As per the indication, the avascular bone segment is thoroughly debrided until bleeding ends are observed. Soft tissue surrounding up to skin is thoroughly debrided (radical debridement). Length of the bone is maintained in comparison with the opposite limb, and the bone is stabilized with appropriate implants. If severe infection or contamination is noted, external fixator is preferred. If the soft tissues are healthy after debridement and sufficient closure can be achieved, even internal fixation with locking plates or IM nails can be considered on case-to-case-based scenarios. Once the bone is stabilized, the bone defect is filled with polymethyl methacrylate (PMMA) bone cement as spacer. The spacer should be shaped before its solidification [Figure 1]. The cylinder-shaped spacer is suitable for the reconstruction of solid bones such as tibia or femur. Pebble shape and cement beads are used in small bone defects and clavicles particularly. The spacer should be as big as possible, without compromising the soft tissue and the skin closure. Cement should wrap the bone extremities on 1 or 2 cm. During the phase of solidification, soft tissues are protected from heat with a piece of glove, and saline irrigation to the surrounding tissues. The main pitfall is to put the cement without wrapping the extremities of the bone ends, which is subsequently a factor of nonunion between the graft and the extremities.
Figure 1: Stage 1 Masquelet technique: Picture showing cement spacer insertion over the defected area after bridge plating

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Adding antibiotics has no role in promoting tissue regeneration capacity of induced membrane. Even plain PMMA bone cement can be used in the Masquelet technique for induced membrane formation. However, in cases of infection and compound wounds, adding of antibiotics provides a high local concentration of the drugs (minimum inhibitory concentrations value of 3–10) which benefits in the eradication of infection. Broad-spectrum antibiotics such as vancomycin and gentamicin have the properties of heat-stable nature and are hydrophilic, making them as antibiotics of choice. The dosage of antibiotics used per 40 g of PMMA bone cement is 2 g of vancomycin plus 500 mg of gentamycin. After insertion of bone cement spacer (with or without antibiotic), the debrided soft tissues are sutured in layers. In the case of inadequate soft-tissue coverage, a plastic procedure to cover the skin defect is also performed in Stage 1. Proper soft-tissue coverage will enhance vascularization and promotion of good induced membrane that is needed for a successful outcome.

Timing between stages

It is apt only to take up Stage 2 after membrane maturation. Membrane activity is maximum at 4–6 weeks, peak being at 4 weeks. Whenever there is no infection, the right time for the second stage is 4 weeks, but it can only be done if the infection markers are settled, and the wound coverage is healed well. Depending on the clinical scenario, it can be staged between 4 and 8 weeks with prerequisite of healed soft-tissue coverage.

Second stage

A few weeks later (6–8 weeks), the cement spacer is removed, and the cavity formed by the induced membrane is filled up with bone graft. Bone graft at this stage acts as a foreign body that is likely to reactivate the biological properties of the membrane, the main role of which is to prevent the resorption of the graft. Corticalization of the reconstructed bone segment is acquired in a few months. The patient is always assessed clinically before Stage 2 procedure. If no clinical signs of infection, inflammatory markers are a part of workup to plan further.

At the second stage, the block of cement spacer must be exposed directly without dissecting the membrane from the surrounding tissues. The cement is broken with osteotome and hammer. The cavity is gently cleaned. Two points should be emphasized: (a) the medullary cavities of the extremities must be cleaned and curetted and (b) small bone chips must be detached from the extremities, maintaining their insertion to the surrounding membrane. Small pieces of graft will be placed between these vascularized chips and the bone extremities, which will avoid a nonunion.

At this stage, if there are any signs of infection, Stage 1 is repeated without proceeding to Stage 2 of the technique. After ensuing there is no evidence of infection and the tubular sleeve of induced membrane is maintained, the size of the bony defect is assessed. In cases of bone stabilized with external fixator in Stage 1, the fixator is removed and rigid internal fixation with an appropriate choice of implant is done. Bone graft is filled in the defect within the induced membrane. The membrane is closed over the graft with adherent soft tissues.

Graft composition

Autografts and allografts are commonly used in grafting the bone defects within the induced membrane.[3],[7],[8]

Autograft

Cancellous autograft from iliac crest is the main source of bone graft. The graft is routinely harvested as chips or morcelized[4] and used. In cases of longer bone defects, fibular grafts can be used as strut support, particularly in metaphyseal distal femur. Reconstruction of the femur needs an intercalated nonvascularized fibular segment which is placed inside the membrane on the medial aspect of the reconstruction to counteract the bending varus forces. This fibular segment is multiperforated with a small drill to promote its revascularization by the membrane. Harvesting graft in sleevers was noted to have a faster rate of incorporation, particularly in large-sized defects [Figure 2].
Figure 2: (a) Bone graft (autograft and allograft) for Stage 2 Masquelet technique. Note the allograft content should be <33% of the total graft quantity. (b) Bone graft harvested in sleevers on the left side and allograft to the right

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Allograft

Allografts can be mixed to autografts to expand the volume. If used, the autografts should never be more than 33% of the graft constitute [Figure 2].

Key Tips for Successful Masquelet Technique

The induced membrane technique is not a technique for treating bone infection. Some series report failures of bone reconstruction because of recurrent infection and conclude failure of the technique itself which is a great misunderstanding. The technique can be used once the infection is definitively eradicated. Sometimes, healing of infection implies iterative bone and soft-tissue debridement which may require nondefinitive stabilization. Debridement of unhealthy tissues and maintaining viable vascular healthy soft tissues is the key factor that helps to promote good vascularization of the membrane which is key to graft incorporation and bone union. One mistake is to think the vascularization of the membrane allows the healing of infection. Appropriate Soft tissue reconstruction techniques to achieve a health and well perfuses soft tissue envelope of the defective areas should be employed. If the spacer is impregnated with antibiotics, the cement should be prepared in a way to maximize its porosity (add the antibiotic powder last to the PMMA paste).[9]

The most commonly noted complication - graft host bone nonunion or delayed incorporaton of graft in Masquelet technique can be avoided by inserting the bone cement spacer on to the normal periosteum at the bone defect area for at least 1.2 cm, facilitating induction of the membrance even at the graft- bone junctions. The cement could also be invaginated into the canal for better stability [Figure 3]. In Stage 2, careful handling of the induced membrane (maintaining its integrity and vascularity) is very essential. The bone edges at both sides of the defect need further debridement until bone ends bleed. The medullary canal needs to be opened, allowing endosteal communication to the grafted defect. Furthermore, after grafting, the induced membrane should be sutured without tension.
Figure 3: A case of compound distal femur communited fracture. (a) Preoperative X-ray thigh with knee anteroposterior and lateral views showing metaphyseal communited fracture distal end femur. (b) Postoperative X-rays showing debridement of communited nonviable bone fragments and insertion of bone cement spacer in a metaphyseal defect. The cement spacer extends onto the edges of bone up to 1 cm. (c) Follow-up X-ray showing consolidated bone graft after Stage 2 Masquelet procedure

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  Discussion Top


Masquelet technique has a lower learning curve when compared to other limb reconstruction methods, i.e., Ilizarov fixator application, limb reconstruction system (LRS) application, and taylor spatial frame (TSF) application.[5],[10] Time duration of the procedure in comparison with other limb reconstructive methods is faster. The induced membrane promotes faster incorporation of the bone graft, thereby taking less time to bone union.[5] Circular fixators, particularly in the periarticular region, are cumbersome and cause certain obstacles for the joint ranges of motion (ROM). Masquelet technique offers a better outcome in periarticular regions as the patient can mobilize early without any obstacle to ROM due to implants.[10]

There are extended indications and applications of the Masquelet technique to various conditions focusing on the principle of induced membrane. Certain modifications based on contents of the graft or substitutes have been described in the literature which also yield good results on case-to-case scenarios.

Umbilical stem cells

The application of allogeneic umbilical cord–mesenchymal stem cells (UC-MSC), bone morphogenetic protein (BMP-2) mixed with hydroxyapatite bone substitute in Masquelet technique is a viable method in treating critical-sized bone defects and provides an effective way to overcome nonunion caused by large defects. The Umbilical Cord - Mesenchymal Stem cells (UC-MSC) are usually isolated from an umbilical cord obtained from a healthy donor by using multiple harvest explants method and are cryopreserved.[11] This works on the Giannoudis' “diamond concept” in tissue engineering. The diamond concept refers to the availability of osteoinductive mediators, osteogenic cells, an osteoconductive matrix (scaffold), optimum mechanical environment, and adequate vascularity to enhance bone healing.[12]

Reamer irrigation aspirate

With the advent of a new bone-graft harvesting device – the reamer–irrigator–aspirator (Synthes) – an additional source of bone is now available to treat fracture nonunions. The aspirate from reamer irrigator system is mixed with allograft substitutes, thus avoiding graft site morbidity to the patients.[13]

Graft volume expanders

The volume of the graft should be adequate to cover the entire area of the defect but should not be excessive to prevent closure of the membrane. When the graft volume obtained is not adequate to fill the defect, further expansion of the volume can be achieved by mixing the autologous bone graft (ABG) with allograft, xenograft, or synthetics (tricalcium phosphate granules).[14] An alternative volume expander, a gelatin sponge, was also suggested, but it was noted that it occupied more volume, thus weakening the residual bone formed. The ideal ratio between autograft and volume expanders should be 7:3 (at least 70% autograft and 30% volume expander). Enhancement of the biological properties of the ABG can be achieved by adding osteoinductive and/or osteogenic materials (BMPs, demineralized bone matrix, and platelet-rich plasma).[15]

Nail-cage graft constructs

The use of interpositional cages into the bone defects was first reported by Cobos et al.[16] The use of additional mesh cage-filled bone graft restores osseous continuity across the ends of the bone defect. The IM nail-cage construct allows safe transmission of load across the defect with weight-bearing even during the early phase of treatment. The only setback of this technique is that the evaluation of radiological union is obliterated by the presence of titanium cage on X-rays.[17]


  Conclusion Top


Masquelet technique promotes bone union as well as improves limb function while treating traumatic bone defects. Its application is not influenced by the shape and length of bone defects. A systematic approach is necessary, beginning with eradication of the infected bone and soft tissue. Various resection methods, fixation strategies, antibiotic additives, and types of bone grafts or substitutes can be used. However, careful planning of reconstruction in Stage 2 with adequate bone graft or substitutes should be taken care while execution. Principles of the Masquelet technique while inserting the spacer extending onto the host bone and handling of the induced membrane are key parameters in a successful outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
    
2.
Masquelet AC. Muscle reconstruction in reconstructive surgery: Soft tissue repair and long bone reconstruction. Langenbecks Arch Surg 2003;388:344-6.  Back to cited text no. 2
    
3.
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. 3
    
4.
Wang X, Wei F, Luo F, Huang K, Xie Z. Induction of granulation tissue for the secretion of growth factors and the promotion of bone defect repair. J Orthop Surg Res 2015;10:147.  Back to cited text no. 4
    
5.
Kasha S, Rathore SS, Kumar H. Antibiotic cement spacer and induced membrane bone grafting in open fractures with bone loss: A case series. Indian J Orthop 2019;53:237-45.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Kasha S, Yalamanchili RK. The masquelet technique in an extruded talus injury after open peri-talar dislocation – A case report. Trauma Case Rep 2021;36:100559. doi:10.1016/j.tcr.2021.100559. Published Ahead of Print Online.  Back to cited text no. 6
    
7.
Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg 2015;23:143-53.  Back to cited text no. 7
    
8.
Mauffrey C, Hake ME, Chadayammuri V, Masquelet AC. Reconstruction of long bone infections using the induced membrane technique: Tips and tricks. J Orthop Trauma 2016;30:e188-93.  Back to cited text no. 8
    
9.
Masquelet AC. Induced membrane technique: Pearls and pitfalls. J Orthop Trauma 2017;31 Suppl 5:S36-8.  Back to cited text no. 9
    
10.
Giannoudis PV, Harwood PJ, Tosounidis T, Kanakaris NK. Restoration of long bone defects treated with the induced membrane technique: Protocol and outcomes. Injury 2016;47 Suppl 6:S53-61.  Back to cited text no. 10
    
11.
Dilogo IH, Primaputra MR, Pawitan JA, Liem IK. Modified masquelet technique using allogeneic umbilical cord-derived mesenchymal stem cells for infected non-union femoral shaft fracture with a 12 cm bone defect: A case report. Int J Surg Case Rep 2017;34:11-6.  Back to cited text no. 11
    
12.
Moghaddam A, Zietzschmann S, Bruckner T, Schmidmaier G. Treatment of atrophic tibia non-unions according to 'diamond concept': Results of one- and two-step treatment. Injury 2015;46 Suppl 4:S39-50.  Back to cited text no. 12
    
13.
Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi masquelet technique for segmental bone defect nonunions: A review of 25 cases. Injury 2010;41 Suppl 2:S72-7.  Back to cited text no. 13
    
14.
Ma YF, Jiang N, Zhang X, Qin CH, Wang L, Hu YJ, et al. Calcium sulfate induced versus PMMA-induced membrane in a critical-sized femoral defect in a rat model. Sci Rep 2018;8:637.  Back to cited text no. 14
    
15.
Kanakaris NK, Giannoudis PV. Clinical applications of bone morphogenetic proteins: Current evidence. J Surg Orthop Adv 2008;17:133-46.  Back to cited text no. 15
    
16.
Cobos JA, Lindsey RW, Gugala Z. The cylindrical titanium mesh cage for treatment of a long bone segmental defect: Description of a new technique and report of two cases. J Orthop Trauma 2000;14:54-9.  Back to cited text no. 16
    
17.
Gavaskar AS, Parthasarathy S, Balamurugan J, Raj RV, Chander VS, Ananthkrishnan LK. A load-sharing nail – Cage construct may improve outcome after induced membrane technique for segmental tibial defects. Injury 2020;51:510-5.  Back to cited text no. 17
    


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