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

Abstract

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.

Fibula lengthening then centralization for the treatment of pseudoarthrosis at the middle third of tibia with large leg-length discrepancy – A case report

“…Implantation of large amounts of allograft, induced membrane technique or non-vascularized autogenous fibular graft for reconstruction of large tibial defects had been associated with greater risk of infection, graft rejection, fracture, nonunion, and fear of disease transmission, especially when associated with extensive scarring, and the fibular graft may not undergo hypertrophy [5] , [6] , [10] . It also did not solve the leg-length discrepancy.…”

“…It provided a large graft of the ipsilateral fibula raised on a pedicle of the peroneal artery, aligned and fixed to the tibia; avoiding exposure of the site that is vulnerable to infection and facilitated wound healing without prolonged hospitalization. The Masquelet technique was relatively ineffective in achieving union in the reconstruction of great tibial defects and was associated with a high rate of infection [5] , [6] . However, the leg-length discrepancy and an acceptable limb alignment had not been solved by the abovementioned techniques [4] , [7] .…”

Advances in 3D printing of composite scaffolds for the repairment of bone tissue associated defects

“…14 Lengthy treatment time, pain during bone transport, disruption of the patient's daily activities is some of the disadvantages associated with the Ilizarov technique. 15 Tissue engineering has the potential to overcome all the abovelisted limitations of conventional techniques. More specifically, for the defects in bone alone (vascularized or non-vascularized), cartilage alone and in osteochondral regions.…”

“…An external fixation device helps in the transposition and is removed after the consolidation of the newly formed bone 14 . Lengthy treatment time, pain during bone transport, disruption of the patient's daily activities is some of the disadvantages associated with the Ilizarov technique 15 …”

Effects of PMMA spacer loaded with varying vancomycin concentrations on bone regeneration in the Masquelet technique

“…Many studies have recommended the use of antibiotic-loaded PMMA cement during the first stage of Masquelet 14 – 16 . Additionally, a systematic review and a meta-analysis have also suggested that the antibiotic-loaded PMMA cement might prevent repeated surgeries for bone grafting 17 . Previous studies have proved that the inclusion of antibiotics in the PMMA spacer can alter the characteristics of the induced membrane 18 , and that antibiotics play an important role in the gene expression profile of induced membrane and the regeneration of infected defects 19 .…”