Adding a Fibular Strut Allograft to Intramedullary Nail and Cancellous Autograft During Stage II of the Masquelet Technique for Segmental Femur Defects: A Technique Tip

Abstract

Reconstruction of segmental diaphyseal bone defects has been a major challenge in limb salvage surgery. Staged reconstruction as first described by Masquelet is a common strategy to deal with this problem in limb salvage surgery. One consequence of this technique is a time period of prolonged limited weightbearing while the segmental defect heals. The purpose of this study was to describe an adjunctive technique for stage II of the Masquelet procedure and retrospectively analyze the outcome and weight bearing progression of 3 patients who sustained femur fractures with significant bone loss and underwent this technique. A retrospective chart review was performed. The patients (2 males, 1 female with an average age of 36.6 years) all sustained segmental femur fractures which resulted in significant bone loss. Induced membrane technique with adjunct use of a fibular strut allograft was performed after initial stabilization and PMMA spacer placement. All three patients went on to union and full weight bearing after being treated by the described technique. All the patients were allowed toe-touch weight bearing immediately after surgery and all progressed to weight bearing as tolerated at an average of 3.6 months. Using a fibular strut allograft as an adjunct to the induced membrane technique serves as a biologic and mechanical scaffold and may allow earlier weightbearing.

Bone Bricks: The Effect of Architecture and Material Composition on the Mechanical and Biological Performance of Bone Scaffolds

“…First, a combination of cement spacer and induced membrane is used to fill the defected area. 22 Second, a biological implant replaces the cement spacer, which is impermeable, biological, and vascular-active. 22 However, autografts present some limitations such as morbidity in the donor site, pain, long hospitalization time, limited quantity, needing general anesthesia during the surgery, extended nonweight-bearing, graft hypertrophy, and the risk of hematoma and deep infection.…”

“…Distraction osteogenesis involves a modular-ring external fixator (Ilizarov apparatus) that stimulates the blood flow, allows early bearing, and creates good-quality bone tissue. , However, it is a technique that requires complex procedures leading to infections, nerve and blood vessel damage, chronic pain, and long hospitalization. , Masquelet and Begue developed a new concept based on a two-stage technique treating bone injuries in infected and noninfected conditions. First, a combination of cement spacer and induced membrane is used to fill the defected area . Second, a biological implant replaces the cement spacer, which is impermeable, biological, and vascular-active .…”

“…First, a combination of cement spacer and induced membrane is used to fill the defected area . Second, a biological implant replaces the cement spacer, which is impermeable, biological, and vascular-active . However, autografts present some limitations such as morbidity in the donor site, pain, long hospitalization time, limited quantity, needing general anesthesia during the surgery, extended nonweight-bearing, graft hypertrophy, and the risk of hematoma and deep infection. , Therefore, it is clear that novel bone replacements are highly demanded and must be bioactive, biodegradable, biocompatible, bespoke, resistant to infections, cost-effective, and have high porosity to enable cell attachment and vascularization, providing similar mechanical and biological properties as bone tissue. , …”

Structural Allograft and Induced Membrane Technique for Treatment of 10-cm Segmental Femoral Bone Defect

“…Regarding the use of structural allografts in IM reconstructions, there are only 2 reports in the literature. Niccolai et al 12 described this technique to treat a 6-cm segmental bone defect in an infected nonunion of the proximal femur, and Ramos et al reported the use of fibular strut allograft and cancellous autograft in 3 femoral bone defects 13 .…”

The Basic Science Behind the Clinical Success of the Induced Membrane Technique for Critical-Sized Bone Defects

“…A different study compared the outcomes of fixation methods for treating bone defects with the IMT in the tibia and the femur 58 . A small study of only femoral defects suggested adding a fibular strut allograft after initial stabilization and placement of the cement spacer to improve patient outcomes 59 . All 3 of the patients achieved union and were able to bear weight as tolerated at an average of 3.6 months postoperatively.…”