Comparison of the clinical outcomes between vascularized bone graft and the Masquelet technique for the reconstruction of Gustilo type III open tibial fractures

Abstract

Background Gustilo type III tibial fractures commonly involve extensive soft tissue and bony defects, requiring complex reconstructive operations. Although several methods have been proposed, no research has elucidated the efficacies and differences between vascular bone graft (VBG) and the Masquelet technique (MT) to date. We aimed to evaluate and compare the clinical effectiveness of VBG and the MT for the reconstruction of Gustilo type III tibial fractures. Methods This retrospective cohort study enrolled patients who underwent reconstruction for Gustilo type III tibial fractures using VBG or the MT in a single center from January 2000 to December 2020. The patients’ demographics, injury characteristics, and surgical interventions were documented for analysis. The clinical outcomes including union status, time to union, postoperative infections, and the causes of union failure were compared between the two groups. Results We enrolled 44 patients: 27 patients underwent VBG, and 17 underwent MT. The average union time was 20.5 ± 15.4 and 15.1 ± 9.0 months in the VBG and MT groups, respectively (p = 0.232). The postoperative deep infection rates were 70.4% and 47.1% in the VBG and MT groups (p = 0.122), respectively. Though not statistically significant, the VBG group had a shorter union time than did the MT group when the bone defect length was > 60 mm (21.0 ± 17.0 versus 23.8 ± 9.4 months, p = 0.729), while the MT group had a shorter union time than did the VBG group when the bone defect was length < 60 mm (17.2 ± 5.6 versus 10.7 ± 4.7 months, p = 0.067). Conclusions VBG and MT are both promising reconstruction methods for Gustilo type III tibial fractures. VBG appears to have more potential in reconstructing larger bone defects, while MT may play an important role in smaller bone defects, severe surgical site infections, and osteomyelitis. Therefore, flexible treatment strategies are required for good outcomes in Gustilo type III open tibial fractures.

A review of 10 patients treated with the masquelet technique and microsurgical technique combined for Gustilo type III open tibial fractures

“…Wang et al’s study revealed a mean union time of 6.1 months (range, 5 to 8 months) [ 9 ]. However, despite an even shorter average length of bone loss (5.3 and 5.1 cm), a much longer mean union time was indicated in the investigations of Zoller et al and Lan et al investigations (17.2 and 15.1 months, respectively) [ 15 , 16 ]. In our current study, the union time of the fracture falls between the two groups, with an average union time of 12.2 months.…”

“…This finding is consistent with the findings of Masquelet, who reported that bone union time is not dependent on the length of bone loss [ 17 , 18 ]. Notably, there was only one postoperative superficial infection in Kang’s study and two postoperative superficial infections in Wang’s study, whereas postoperative infections in Zoller and Lan’s study were associated with a high occurrence of postoperative osteomyelitis which suggested that a sterile surgical environment is a significant contributing factor to prolonged union time [ 15 , 16 ]. However, in our study, the bone union time was relatively longer than that in Wang’s investigations.…”

“…However, in our study, the bone union time was relatively longer than that in Wang’s investigations. There are three possible explanations for this discrepancy: [ 1 ] Like the majority of studies that reported an average union time within one year using the Masquelet technique, the length of the bone defect was generally approximately 5 cm [ 16 ] [ 2 ]. This may be attributed to case-specific variations given the small sample size in this study [ 3 ].…”

Tibial bone loss

“…Although there are not many direct comparative studies, some have shown similar outcomes when comparing vascularized bone grafting to the induced membrane and distraction osteogenesis techniques. 29 , 30 …”

Contemporary management of open extremity fractures: What you need to know

“…The various technical modalities for bone defect reconstruction, including bone grafting, temporary spacers and staged Masquelet technique, distraction osteogenesis, and vascularized bone transfer, are beyond the scope of this review article and covered elsewhere in the literature. [63][64][65] A case example of a patient with an infected nonunion from a high-energy open humerus shaft fracture managed by free microvascular fibular bone transfer is shown in Figure 3. New innovative modalities aimed at by The IIIB open tibia shaft fracture was managed by surgical debridement and temporizing spanning external fixation (A).…”