ObjectiveTo investigate the effect of Masquelet technique combined with artificial dermis on repairing bone and soft tissue defects in rabbits, and to observe the microstructure and vascularization of induced membrane, so as to guide the clinical treatment of Gustilo-Anderson type Ⅲ open fracture with large bone defect and soft tissue defect.MethodsEighty male rabbits, weighing 2.03-2.27 kg (mean, 2.11 kg), were selected. The bilateral thighs of 64 rabbits were randomly divided into experimental group and control group, the remaining 16 rabbits were sham operation group. Bone and soft tissue defect models of femur were made in all rabbits. In the experimental group, the first stage of Masquelet technique was used [polymethyl methacrylate bone cement was filled in bone defect area] combined with artificial dermis treatment; in the control group, the first stage of Masquelet technique was used only; in the sham operation group, the wound was sutured directly without any treatment. Four rabbits in sham operation group and 16 rabbits in the experimental group and control group were sacrificed at 2, 4, 6, and 8 weeks after operation, respectively. The induced membranes and conjunctive membranes were observed on both sides of the femur. The membrane structure was observed by HE staining, and the microvessel density (MVD) was counted by CD34 immunohistochemical staining.ResultsGross observation showed that the spongy layer of collagen in the artificial dermis of the experimental group disappeared completely at 4 weeks after operation, and the induced membrane structure of the experimental group and the control group was complete; the membrane structure of the control group was translucent, and the membrane structure of the experimental group was thicker, light red opaque, accompanied by small vessel proliferation. The membrane structure of the experimental group and the control group increased gradually from 6 to 8 weeks after operation. In the sham operation group, only scar tissue proliferation was observed over time. HE staining showed that a large number of muscle fibers and a small amount of collagen fibers proliferation with inflammatory cell infiltration could be seen in the experimental group and the control group at 2 weeks after operation; most of the sham operation group were muscle fibers with a small amount of interfibrous vessels. At 4 weeks after operation, collagen fibers increased and some blood vessels formed in the experimental group. The nuclei of collagen fibers in the control group were round-like, while those in the experimental group were flat-round. At 6 and 8 weeks after operation, the collagen fibers in the experimental group and the control group increased. The nuclei of the collagen fibers in the control group were still round-like. The nuclei of the collagen fibers in the experimental group were fusiformis and deeply stained compared with those in the control group. The proliferation of blood vessels was observed in both groups, and the number of proliferation vessels in the experimental group was increased compared with that in the control group. In the sham operation group, a large number of fibroblasts still appeared, but no significant proliferation of blood vessels with time was observed. CD34 immunohistochemical staining showed that MVD in each group increased gradually with the prolongation of time after operation. MVD in the sham operation group was significantly higher than that in the experimental group and the control group at 2 weeks after operation, and significantly smaller than that in the experimental group and the control group at 4, 6, and 8 weeks after operation (P<0.05). MVD in the experimental group was significantly higher than that in the control group at 4 and 6 weeks after operation (P<0.05), but there was no significant difference in MVD between the two groups at 2 and 8 weeks (P>0.05).ConclusionMasquelet technique combined with artificial dermis in the treatment of femoral bone defect and soft tissue defect in rabbits can significantly promote the vascularization of membrane structure at 4-6 weeks after operation. The combination of these two methods has guiding significance for the treatment of Gustilo-Anderson type Ⅲ open fracture with bone and soft tissue defects.
ObjectiveTo investigate the effectiveness of modified induced membrane technique and pedicled skin (myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes. Methods A clinical data of 22 diabetic patients with chronic tibial osteomyelitis between January 2017 and March 2019 was retrospectively analyzed. There were 15 males and 7 females with an average age of 52 years (range, 44-65 years). The course of diabetes was 3-12 years (mean, 6.1 years). The course of chronic osteomyelitis was 4 months to 7 years (mean, 3.3 years). The chronic osteomyelitis was rated as type Ⅲ in 9 cases and as type Ⅳ in 13 cases according to the Cierny-Mader classification criteria. Bacterial culture showed 21 cases of single bacterial infection and 1 case of mixed bacterial infection. Preoperative color Doppler ultrasound and CT angiography confirmed that the anterior and posterior tibial arteries were unobstructed. In the first stage of treatment, the bone and soft tissue defects were filled with antibiotic bone cement after the lesion was thoroughly debrided; the length of bone defect was 4-9 cm (mean, 5.6 cm), and the size of soft tissue defect was 5 cm×2 cm to 10 cm×7 cm. After 7-10 days, the bone cement was removed and a new antibiotic bone cement was filled into the bone defect. Meanwhile, the pedicled skin (myocutaneous) flap was performed to repair the wound. After 7-12 weeks, the inflammatory indexes returned to normal, autogenous iliac bone or combined with artificial bone was used to repair the bone defect in the second stage of treatment. The wound healing, bone defect healing, complications, and the number of successful treatments were recorded. The satisfaction of the skin flap efficacy and the function of the affected limb were evaluated. ResultsLocal necrosis of the skin flap occurred in 3 cases after operation, leading to delayed healing of the wound; the other 19 flaps survived successfully, leading to primary healing of the wound. The skin grafts survived completely and the incisions healed by first intention. All cases were followed up 13-28 months with an average of 20 months. The infection recurred in 2 cases within 12 months after operation, and the bone defects healed after treated by modified induced membrane technique. The bone defect healing rate was 100%; the bone healing time was 6-10 months, with an average of 8.9 months; the infection control rate and successful treatment rate were 90.9% (20/22) and 90.9% (20/22), respectively. At 12 months after operation, according to the satisfaction evaluation standard of skin flap efficacy formulated by ZHANG Hao et al., all were satisfied. According to Johner-Wruhs adjacent joint function method, the limb function recovery was excellent in 13 cases, good in 7 cases, and fair in 2 cases, with an excellent and good rate of 90.9%. ConclusionFor the treatment of chronic tibial osteomyelitis in patients with diabetes without vascular occlusion, the modified induced membrane technique and pedicled skin (myocutaneous) flap can repair bone and soft tissue defects, and control the infection at the same time, the short- and medium-term effectiveness are good.
ObjectiveTo investigate the effectiveness of flap combined with induced membrane technique in treatment of post-traumatic tibial osteomyelitis with soft tissue defect. Methods A clinical data of 33 patients with post-traumatic tibial osteomyelitis with soft tissue defect who met the selection criteria between August 2015 and October 2018 was retrospectively analyzed. There were 21 males and 12 females. The age ranged from 19 to 70 years, with an average of 39 years. The osteomyelitis located in the upper 1/3 of tibia in 8 cases, in the middle 1/3 of tibia in 14 cases, and in the lower 1/3 of tibia in 11 cases. According to Cierny-Mader classification standard, 19 cases of osteomyelitis were type Ⅲ and 14 cases were type Ⅳ. The duration of osteomyelitis ranged from 2 months to 20 years (median, 3 months). In the first-stage operation, after radical debridement, the length of bone defect was 1.5-12.5 cm (mean, 5.0 cm) and the size of soft tissue defects ranged from 5 cm×4 cm to 15 cm×12 cm. Bone cement containing antibiotics was implanted into the bone defect and the personalized flap was used to repair the wound. After the wound healed at 6-8 weeks and the infection was controlled, bone grafting was performed to repair bone defects in the second-stage operation. Results The flaps survived completely after the first-stage operation in 29 cases. Partial necrosis of the flap occurred in 4 cases and healed after surgical dressing change. All the incisions healed by first intention after the second-stage operation. All patients were followed up 24-32 months (mean, 28 months). All the bone grafts healed after operation, and the radiographic healing time was 3-9 months (mean, 5 months). The clinical healing time was 4-14 months (mean, 8 months). There was no recurrence of osteomyelitis during follow-up. At last follow-up, according to Johner-Wruhs evaluation criteria, the limb function was excellent in 27 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 93.9%. Conclusion For the post-traumatic tibial osteomyelitis with soft tissue defect, the flap combined with induced membrane technique is a reliable and effective method and can effectively restore the function of lower limbs with satisfactory effectiveness.
ObjectiveTo investigate the effectiveness of debridement-vacuum sealing drainage (VSD)-modified external fixation antibiotic-impregnated cement semi-open technique in treatment of chronic ulcer wounds. MethodsClinical data of 43 patients with chronic ulcer wounds who met the selection criteria and admitted between January 2019 and June 2023 were retrospectively analyzed. Among them, 23 cases were treated with debridement-VSD-modified external fixation antibiotic-impregnated cement semi-open technique (improved group), and 20 cases were treated with debridement-VSD-traditional antibiotic-impregnated cement technique (control group). There was no significant difference in gender, age, constituent ratio of patients with type 2 diabetes mellitus, constituent ratio of patients with smoking history, body mass index, wound site, and other baseline data between the two groups (P>0.05). The healing quality and healing time, the positive rate of bacterial culture after bone cement coating, the loosening rate of bone cement, the number of operations, the number of hospitalizations, the length of hospitalization, and the cost of hospitalization were recorded and compared between the two groups. Results Compared with the control group, the positive rate of bacterial culture after bone cement coating and the loosening rate of bone cement in the improved group was significantly lower, as well as the number of operations, the number of hospitalizations, the length of hospitalization, and hospitalization cost significantly reduced (P<0.05). Wound repair was completed in both groups without amputation. The wound healing quality of the improved group was better than that of the control group and the wound healing time was shorter, the differences were significant (P<0.05). All patients were followed up 1-5 years (mean 3.4 years), and no ulcers recurred during follow-up. ConclusionDebridement-VSD-modified external fixation antibiotic-impregnated cement semi-open technique in the treatment of chronic ulcer wounds can effectively reduce the loosening rate of bone cement, facilitate the induced membrane formation and wound healing, and significantly reduce the number of operations and shorten the length of hospital stay.
ObjectiveTo investigate the causes of spontaneous osteogenesis of Masquelet technique induced membrane. MethodsForty-two male Sprague-Dawley rats aged 7-9 weeks were selected to establish a critical-sized bone defect of the right middle femur model. Then the rats were randomly divided into 4 groups, with 12 rats in groups A-C and 6 rats in group D. The bone defects in groups A-C were filled with vancomycin-loaded polymethyl methacrylate bone cement spacers. Then the Kirschner wires were used for intramedullary fixation in groups A and B, and the bone cement was used to connect the bone cement spacers and the bone ends in group B. The steel plate was used to fixation in group C. The bone defect in group D was only fixed with steel plate as a blank control group. The general condition was observed after operation. At 5 weeks after operation, 6 rats in groups A-C were selected for STRO-1 immunohistochemical staining to observe the content of mesenchyme stem cells (MSCs) in the induced membrane (STRO-1+ cells). At 12 weeks after operation, the remaining rats in groups A-D were taken for X-ray observation, gross observation, and histological observation (HE, safranin O-green staining) to observe the spontaneous osteogenesis of the membrane.Results All rats in the 4 groups survived until the completion of the experiment. At 5 weeks after operation, the immunohistochemical staining showed that group B was negative, while the contents of MSCs in the induced membrane in groups A and C were 14.20%±1.92% and 5.00%±0.71%, respectively, with a significant difference (P<0.05). At 12 weeks after operation, group A showed that the new bone formed at the osteotomy site and growth towards the center of the bone defect, with an average length of 3.1 mm on one side; and the presence of bone, cartilage lesions, fibers, and a small amount of neovascularization were observed in the induced membrane. Group C only had a small amount of new bone at the osteotomy site, and a small amount of neovascularization in the induced membrane. Groups B and D did not have any new bone, but bone resorption or atrophy at the osteotomy site. ConclusionAlthough the Masquelet technique induced membrane has osteogenesis, the key factor for the spontaneous osteogenesis is the bone marrow overflow from the bone marrow cavity providing MSCs. The spontaneous osteogenesis of the induced membrane belongs to endochondral ossification.