Staged reconstruction of diaphyseal fractures with segmental defects: Surgical and patient-reported outcomes

Zoller, Stephen D.; Cao, Lei; Smith, Rhonda L.; Sheppard, William; Lord, Elizabeth L.; Hamad, Christopher D.; Ghodasra, Jason H.; Lee, Choongyeop; Jeffcoat, Devon M.

doi:10.1016/j.injury.2017.06.018

Cited by 16 publications

(13 citation statements)

References 31 publications

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“…Outcomes of trauma and tumor treatment are detailed in Tables 4 and 5 , respectively. A specific analysis of the two-step Masquelet technique 28 , 29 , 36 , 39 , 40 underlined a primary union rate of 53%, a complication rate of 15.0%, a reintervention rate of 27.2%, and a failure rate of 15.0%. Finally, in the studies on bone allografts or autografts used alone 17 – 20 , 22 , 24 , 25 , 30 , 33 , 42 a pooled primary union rate of 87.0%, a time to union of 5.3 months, a complication rate of 31.0%, a reintervention rate of 26%, and a failure rate of 3.9% were reported.…”

Section: Resultsmentioning

confidence: 99%

“…Then, from the end of the 90 s, more and more studies were progressively published, along with a growing interest in other approaches such as bone transport and endoprosthesis 54 , 57 , 60 – 62 , 82 – 84 . Finally, in the last years, all treatments were increasingly addressed but with a focus above all on bone transport and, also due to the impulse of new augmentation procedures, with several studies on bone allograft or autografts 27 – 29 , 31 , 35 , 36 , 45 , 50 , 51 , 53 , 56 , 59 , 77 , 91 .…”

Section: Discussionmentioning

confidence: 99%

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Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

Feltri¹,

Solaro

Martino

et al. 2022

Sci Rep

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To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

Feltri¹,

Solaro

Martino

et al. 2022

Sci Rep

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“…After removing the duplicates, 243 studies were screened, and 30 studies were included in the second phase to assess their eligibility. Eleven reports [10][11][12][15][16][17][18][19][20][21][22] of individual patient data (total of 115 patients) were used for this study. The flow chart of the selection process is presented in Figure 1.…”

Section: Resultsmentioning

confidence: 99%

“…However, there was no standard definition of complete union among the included studies. Some studies defined bone union as 3/4 cortices that showed callus formation as a radiological union; however, some used radiographic union score for tibial fractures (RUST) methodology to determine the union status [19,31]. Furthermore, only few studies provided detailed data regarding comorbidities, bone healing times, and weightbearing times of individual patient; we tried to contact the authors of each study to obtain this information, but our efforts were unsuccessful.…”

Section: Discussionmentioning

confidence: 99%

The Induced Membrane Technique for the Management of Segmental Tibial Defect or Nonunion: A Systematic Review and Meta-Analysis

Hsu

Chen

Chan

et al. 2020

BioMed Research International

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Purpose. To identify the predicting factors for union and infection after applying the induced membrane technique (IMT) for segmental tibial defects. Methods. A systematic review was carried out following the PRISMA guidelines. All databases were searched for articles published between January 2000 and February 2018 using the keywords “Masquelet technique” and “induced membrane technique.” Studies in English reporting more than 5 cases with accessible individual patient data were included. A meta-analysis was performed. Odds ratios (OR) with 95% confidence intervals were calculated. Results. After reviewing, 11/243 studies (115 patients) were finally selected. The mean age of the patients was 43.6 years (range: 18-84 years), and the mean length of the tibial defect was 5.5 cm (range: 0-20 cm). The multivariate logistic regression analysis revealed that the risk factors of postoperative infection after IMT were infected nonunion (p=0.0160) and defect length ≥7 cm (p=0.0291). Patients with postoperative infection after IMT had a lower union rate (p=0.0003). Additionally, the use of an antibiotic polymethyl methacrylate cement spacer reduced the need for surgical revision (p=0.0127). Multiple logistic regression indicated no direct association between the union rate and length of the bone defect. Conclusions. IMT is a reliable and reproducible treatment for segmental tibial defects. However, initial infected nonunion and defect length greater than 7 cm are risk factors for post-IMT infection, and post-IMT infection was statistically related to nonunion.

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“…One consequence of the Masquelet technique, as would be expected with segmental bone loss, is prolonged limited weight bearing on the affected extremity, following the second stage procedure. 2 , 24 - 26 Our technique involves the use of a fibular strut allograft in addition to autograft during the second stage of the procedure that allows for earlier partial weight bearing and maintains the benefits of the induced membrane. We describe this technique with a case series of patients.…”

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confidence: 99%

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

et al. 2020

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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.

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Staged reconstruction of diaphyseal fractures with segmental defects: Surgical and patient-reported outcomes

Cited by 16 publications

References 31 publications

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

The Induced Membrane Technique for the Management of Segmental Tibial Defect or Nonunion: A Systematic Review and Meta-Analysis

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

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