Current overview on masquelet technique

Srinivas Kasha; Ranjith Kumar Yalamanchili

doi:10.4103/joasis.joasis_30_21

REVIEW ARTICLE

Year : 2021 | Volume : 18 | Issue : 2 | Page : 44-48

Current overview on masquelet technique

Srinivas Kasha¹, Ranjith Kumar Yalamanchili²
¹ Department of Orthopaedics, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
² Department of Orthopaedics, ESIC Medical College, Hyderabad, Telangana, India

Date of Submission	05-Dec-2021
Date of Acceptance	07-Dec-2021
Date of Web Publication	27-Jan-2022

Correspondence Address:
Srinivas Kasha
Krishna Institute of Medical Sciences, Secunderabad - 500 003, Telangana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_30_21

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 2023 Apr 1];18:44-8. Available from: https://www.joasis.org/text.asp?2021/18/2/44/336658

Introduction

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

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

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

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.

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