Effectiveness analysis of induced membrane technique in the treatment of infectious bone defect_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

QIU Xusheng ,  CHEN Yixin , QI Xiaoyang , YIN Zhipeng , ZHANG Yan , WANG Zhen

Department of Orthopaedics, Drum Tower Hospital of Nanjing University Medical School, Nanjing Jiangsu, 210008, P.R.China;

Corresponding author：

CHEN Yixin, Email: chenyixin93@126.com

Keywords：

Induced membrane technique; infectious bone defect; debridement; bone cement

DOI：

10.7507/1002-1892.201704002

Video：

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Objective To evaluate the effectiveness of induced membrane technique in the treatment of infectious bone defect. Methods Thirty-six patients (37 bone lesions) with infectious bone defects were treated with induced membrane technique between January 2011 and June 2014. There were 28 males and 8 females with an average age of 36 years (range, 20-68 years). All bone defects were post-traumatic infectious bone defect. The bone defect was located at the tibia and fibula in 24 cases (25 bone lesions), at femurs in 6 cases (6 bone lesions), at ulnas and radii in 2 cases (2 bone lesions), at calcanei in 3 cases (3 bone lesions), and at clavicle in 1 case (1 bone lesion). The average time between onset and the treatment of induced membrane technique was 6.2 months (range, 0.5-36.0 months); 15 patients were acute infections (disease duration was less than 3 months). At the first stage, after the removal of internal fixator (applicable for the patients who had internal fixation), complete debridement of infection necrotic bone tissue and surrounding soft tissue was performed and the bone defects were filled with antibiotic-impregnated cement spacers. If the bone was unstable after debridement, external fixator or plaster could be used for stabilization. Patients received sensitive antibiotics postoperatively. At the second stage (usually 6-8 weeks later), the cement spacer were removed, with preservation of the induced membrane formed by the spacer, and filled the bone defect with autologous iliac bone graft within the membrane. Results The hospitalization time after debridement was 17-30 days (mean, 22.2 days), and the hospitalization time after the second stage was 7-14 days (mean, 10 days). All the flaps healed uneventfully in 16 cases treated with local flap transposition or free flap grafting after debridement. One patient of femur fracture received Ilizarov treatment after recurrence of infection at 11 months after operation; 1 patient of distal femoral fracture received amputation after recurrence of infection at 1 month after operation; 1 patient of distal end of tibia and fibula fractures received ankle arthrodesis after repeated debridements due to the recurrence of infection; 1 patient of tibia and fibula fractures lost to follow-up. The other 32 patients (33 bone lesions) were followed up 1-5 years (mean, 2 years) without infection recurrence, and the infection control rate was 91.7% (33/36). All the patients had bony union, and the healing time was 4-12 months (mean, 7.5 months); no refracture occurred. One patient of femur bone defect had a lateral angulation of 15° and leg discrepancy of 1.5 cm. Superficial pin infection was observed in 7 cases and healed after intensive wound care and oral antibiotics. Adjacent joint function restriction were observed in 6 cases at last follow-up. Conclusion Induced membrane technique is a simple and reliable technique for the treatment of infectious bone defect. The technique is not limited to the size of the bone defect and the effectiveness is satisfactory.

Citation： QIU Xusheng, CHEN Yixin, QI Xiaoyang, YIN Zhipeng, ZHANG Yan, WANG Zhen. Effectiveness analysis of induced membrane technique in the treatment of infectious bone defect. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(9): 1064-1068. doi: 10.7507/1002-1892.201704002 Copy

1.	Lima AL, Oliveira PR, Carvalho VC, et al. Recommendations for the treatment of osteomyelitis. Braz J Infect Dis, 2014, 18(5): 526-534.
2.	Walter G, Kemmerer M, Kappler C, et al. Treatment algorithms for chronic osteomyelitis. Dtsch Arztebl Int, 2012, 109(14): 257-264.
3.	Aronson J. Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method. J Bone Joint Surg (Am), 1997, 79(8): 1243-1258.
4.	Pederson WC, Person DW. Long bone reconstruction with vascularized bone grafts. Orthop Clin N Am, 2007, 38: 23-35.
5.	Masquelet AC. Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction. Langenbecks Arch Surg, 2003, 388(5): 344-346.
6.	Woon CY, Chong KW, Wong MK. Induced membranes——a staged technique of bone-grafting for segmental bone loss: a report of two cases and a literature review. J Bone Joint Surg (Am), 2010, 92(1): 196-201.
7.	Giannoudis PV, Faour O, Goff T, et al. Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury, 2011, 42(6): 591-598.
8.	Taylor BC, French BG, Fowler TT, et al. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg, 2012, 20(3): 142-150.
9.	Chadayammuri V, Hake M, Mauffrey C. Innovative strategies for the management of long bone infection: a review of the Masquelet technique. Patient Saf Surg, 2015, 9: 32.
10.	Hogan A, Heppert VG, Suda AJ. Osteomyelitis. Arch Orthop Trauma Surg, 2013, 133(9): 1183-1196.
11.	Juutilainen V. Posttraumatic osteomyelitis. Suomen Ortopedia ja Traumatologia, 2011, 34: 38-41.
12.	Blaha JD, Calhoun JH, Nelson CL, et al. Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. Clin Orthop Relat Res, 1993, (295): 8-12.
13.	Calhoun JH, Henry SL, Anger DM, et al. The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. Clin Orthop Relat Res, 1993, (295): 23-27.
14.	Walenkamp GH, Kleijn LL, de Leeuw M. Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1-12 years. Acta Orthop Scand, 1998, 69(5): 518-522.
15.	喻胜鹏, 傅景曙, 李伟, 等. Masquelet 技术治疗长骨骨髓炎骨缺损的临床分析. 第三军医大学学报, 2014, 36(15): 1630-1634.
16.	Wang X, Luo F, Huang K, et al. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res, 2016, 5(3): 101-105.
17.	刘欣伟, 周大鹏, 赵勇, 等. 快捷式抗感染占位器结合膜诱导技术治疗感染性骨缺损. 中华创伤骨科杂志, 2015, 17(11): 954-957.
18.	Shinsako K, Okui Y, Matsuda Y, et al. Effects of bead size and polymerization in PMMA bone cement on vancomycin release. Biomed Mater Eng, 2008, 18(6): 377-385.
19.	黄雷, 刘沂, 李瑞海, 等. 一期开放植骨治疗感染性骨折和骨不愈合. 中华外科杂志, 1998, 36: 32-34.
20.	陆维举, 钱宏波, 李斌, 等. 清创后Ⅰ期改良开放式松质骨移植治疗慢性骨髓炎. 中华创伤杂志, 2004, 20(5): 288-290.
21.	喻胜鹏, 杨子洋, 傅景曙, 等. Ⅰ 期自体松质骨移植修复胫骨创伤后骨髓炎骨缺损的临床研究. 第三军医大学学报, 2014, 36(7): 700-703.
22.	Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am, 2010, 41(1): 27-37.
23.	Pelissier P, Masquelet AC, Bareille R, et al. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res, 2004, 22(1): 73-79.
24.	Viateau V, Guillemin G, Calando Y, et al. Induction of a barrier membrane to facilitate reconstruction of massive segmental diaphyseal bone defects: an ovine model. Vet Surg, 2006, 35(5): 445-452.
25.	Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases. Injury, 2010, 41 Suppl 2: S72-77.
26.	Viateau V, Guillemin G, Bousson V, et al. Long-bone critical-size defects treated with tissue-engineered grafts: a study on sheep. J Orthop Res, 2007, 25(6): 741-749.

1. Lima AL, Oliveira PR, Carvalho VC, et al. Recommendations for the treatment of osteomyelitis. Braz J Infect Dis, 2014, 18(5): 526-534.
2. Walter G, Kemmerer M, Kappler C, et al. Treatment algorithms for chronic osteomyelitis. Dtsch Arztebl Int, 2012, 109(14): 257-264.
3. Aronson J. Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method. J Bone Joint Surg (Am), 1997, 79(8): 1243-1258.
4. Pederson WC, Person DW. Long bone reconstruction with vascularized bone grafts. Orthop Clin N Am, 2007, 38: 23-35.
5. Masquelet AC. Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction. Langenbecks Arch Surg, 2003, 388(5): 344-346.
6. Woon CY, Chong KW, Wong MK. Induced membranes——a staged technique of bone-grafting for segmental bone loss: a report of two cases and a literature review. J Bone Joint Surg (Am), 2010, 92(1): 196-201.
7. Giannoudis PV, Faour O, Goff T, et al. Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury, 2011, 42(6): 591-598.
8. Taylor BC, French BG, Fowler TT, et al. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg, 2012, 20(3): 142-150.
9. Chadayammuri V, Hake M, Mauffrey C. Innovative strategies for the management of long bone infection: a review of the Masquelet technique. Patient Saf Surg, 2015, 9: 32.
10. Hogan A, Heppert VG, Suda AJ. Osteomyelitis. Arch Orthop Trauma Surg, 2013, 133(9): 1183-1196.
11. Juutilainen V. Posttraumatic osteomyelitis. Suomen Ortopedia ja Traumatologia, 2011, 34: 38-41.
12. Blaha JD, Calhoun JH, Nelson CL, et al. Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. Clin Orthop Relat Res, 1993, (295): 8-12.
13. Calhoun JH, Henry SL, Anger DM, et al. The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. Clin Orthop Relat Res, 1993, (295): 23-27.
14. Walenkamp GH, Kleijn LL, de Leeuw M. Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1-12 years. Acta Orthop Scand, 1998, 69(5): 518-522.
15. 喻胜鹏, 傅景曙, 李伟, 等. Masquelet 技术治疗长骨骨髓炎骨缺损的临床分析. 第三军医大学学报, 2014, 36(15): 1630-1634.
16. Wang X, Luo F, Huang K, et al. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res, 2016, 5(3): 101-105.
17. 刘欣伟, 周大鹏, 赵勇, 等. 快捷式抗感染占位器结合膜诱导技术治疗感染性骨缺损. 中华创伤骨科杂志, 2015, 17(11): 954-957.
18. Shinsako K, Okui Y, Matsuda Y, et al. Effects of bead size and polymerization in PMMA bone cement on vancomycin release. Biomed Mater Eng, 2008, 18(6): 377-385.
19. 黄雷, 刘沂, 李瑞海, 等. 一期开放植骨治疗感染性骨折和骨不愈合. 中华外科杂志, 1998, 36: 32-34.
20. 陆维举, 钱宏波, 李斌, 等. 清创后Ⅰ期改良开放式松质骨移植治疗慢性骨髓炎. 中华创伤杂志, 2004, 20(5): 288-290.
21. 喻胜鹏, 杨子洋, 傅景曙, 等. Ⅰ 期自体松质骨移植修复胫骨创伤后骨髓炎骨缺损的临床研究. 第三军医大学学报, 2014, 36(7): 700-703.
22. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am, 2010, 41(1): 27-37.
23. Pelissier P, Masquelet AC, Bareille R, et al. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res, 2004, 22(1): 73-79.
24. Viateau V, Guillemin G, Calando Y, et al. Induction of a barrier membrane to facilitate reconstruction of massive segmental diaphyseal bone defects: an ovine model. Vet Surg, 2006, 35(5): 445-452.
25. Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases. Injury, 2010, 41 Suppl 2: S72-77.
26. Viateau V, Guillemin G, Bousson V, et al. Long-bone critical-size defects treated with tissue-engineered grafts: a study on sheep. J Orthop Res, 2007, 25(6): 741-749.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness analysis of induced membrane technique in the treatment of infectious bone defect

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