Orthopaedics & Traumatology: Surgery & Research (2010) 96, 549—553

ORIGINAL ARTICLE

Two-stage reconstruction of post-traumaticsegmental tibia bone loss with nailing

T. Aparda,∗, N. Bigorrea, P. Croniera, F. Duteilleb, P. Bizota, P. Massinc

a Bone Surgery Department, Angers Teaching Hospital Center, 4, rue Larrey, 49033 cedex Angers, Franceb Plastic Surgery Department and Burn Unit, Nantes Teaching Hospital Center,30, boulevard Jean-Monnet, 44093 Nantes cedex 1, Francec Orthopaedics and Traumatology Department, Bichat Hospital, Paris, France

Accepted: 22 February 2010

KEYWORDSFracture;Leg;Bone loss;Bone reconstruction;Induced membrane;Intramedullarynailing

SummaryIntroduction: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al.proposed a two-stage technique: first, debridement and filling of bone loss with an acrylicspacer; second, bone reconstruction by filling with cancellous bone in the space left free (fol-lowing cement removal) inside the so-called self-induced periosteal membrane. In the originallydescribed technique, the fracture site is stabilized by an external fixator, which remains in placethroughout the bone healing process, i.e., often longer than 9 months with all the known dis-advantages of this type of assembly. Following the principle of two-stage reconstruction, wemodified the technique by reconstructing around an intramedullary-locking nail placed in thefirst stage.Hypothesis: This technique prevents the mechanical complications related to external fixatoruse and provides faster resumption of weight-bearing.Patients and methods: Twelve patients were operated for segmental tibial bone loss greaterthan 6 cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis(seven cases). All the patients were operated on in an emergency setting and the first stagewas performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocu-taneous flap (two patients) was necessary during this first step to cover the site and provide goodconditions for secondary bone growth. The follow-up was 39.5 months (range, 12—94 months).Results: Complete weight-bearing was resumed at a mean 4 months. After the second step,

all the patients except one had apparently healed (complete weight-bearing with no pain).Five septic complications occurred after the second step, in one case leading to reconstructionfailure. Four other patients had infectious complications successfully treated (as of the lastfollow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in twoother cases, with no graft loss.

∗ Corresponding author.E-mail address: thomasapard@yahoo.fr (T. Apard).

1877-0568/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.doi:10.1016/j.otsr.2010.02.010

550 T. Apard et al.

Discussion: The use of the intramedullary nail facilitates the Masquelet technique by allowingthe patient to resume weight-bearing more quickly and avoiding secondary fractures. However,the risk of sepsis remains high but can be controlled without compromising the final bone unionin four cases out of five.

Level of evidence: Level IV. Retrospective study.© 2010 Elsevier Masson SAS. All rights reserved.

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econstruction of extended diaphyseal bone loss in theibia is difficult and calls on a variety of techniques: exter-al fixation procedures or microsurgical techniques such asscension of a corticotomized bone fragment with an Ilizarovxator [1], a free vascularized fibular flap [2,3], or thesteomyocutaneous flap [4]. More recently, Masquelet et al.5] described a two-stage technique in which bone is addedometime after the initial episode when the debridementnd cutaneous healing conditions are satisfactory. This tech-ique allows formation of a self-induced membrane aroundhe acrylic spacer placed during the first stage, after initialebridement. According to its advocates, this self-inducedembrane has a double mechanical and biological advan-

age: it prevents penetration of scar tissue in the bone lossrea and it plays an osteoinduction role by producing growthactors (VEGF, TGF-�1) and an osteoinductive factor (BMP-). This membrane is impermeable and hypervascularized.t prevents bone resorption and favors corticalization of theutograft [6,7].

In this technique, the bone is stabilized by an externalxator until union, with time to weight-bearing longer thanmonths in four cases out of 27 (15%) and secondary frac-

ures (two cases before 3 months and two cases after 2 years)5]. In addition, the fixator can disturb plastic surgery. Itstability can be compromised, with infectious complicationst the pinholes [5]. The lower pins are sometimes very closeo the talocrural joint, interfering with rehabilitation.

While following the Masquelet technique, we modifiedhe type of bone fixation by using an intramedullary-lockingail for static fixation in the first stage in 12 cases ofxtended bone loss in the leg. The objective was to achieveone union while shortening the time required to resumeeight-bearing and prevent secondary fractures. The asso-iated question was to determine whether the advantagesn terms of stabilization with nailing were associated withncreased risk of sepsis.

aterial and methods

welve patients (ten males and two females), mean age,1 years (range, 18—74 years), were treated for a crushnjury of the leg.

Diaphyseal bone loss was a mean 8.7 cm (range,

—15 cm), resulting directly from injury and debridementn four cases (mean, 8 cm; range, 6—12 cm), resection ofecrotic bone for treatment of aseptic nonunion in one case9 cm), and resection of osteitic bone for treatment of septiconunion in seven cases (mean, 8 cm; range, 6—15 cm).

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Debridement with bone resection was achieved withouttourniquet, with knife excision of the soft tissue and of

evascularized, necrotic, or infected bone with a reamerslow rotation) until reaching bleeding tissue. After dia-hyseal washing, the bone was stabilized with a solid orollow locking nail (Synthès®) for static fixation, with twocrews above and two screws below the bone loss afterestoration of tibial torsion in accordance with the oppositeide. The length was also adjusted based on the oppositeide, taking care not to cause lengthening or excessivelytretch the soft tissues. The nail diameters ranged from 8 to4 mm, sometimes requiring reaming to prepare the remain-ng diaphysis. The nail length was chosen so as to place theistal end as near as possible to the subchondral bone athe talocrural joint. Once stabilization was obtained, theone loss area was filled with acrylic cement with gen-amicin molded around the nail. In cases with substantialone loss, the cement was applied in several interconnectedieces to facilitate later extraction. The fibula was notxed.

Impermeable aspiration bandaging was placed and all theatients initially received hyperbaric oxygen therapy whileaiting for plastic surgery performed by another surgical

eam of plastic surgeons a few days later (3—8 days), consist-ng in a free muscle flap in ten cases and a pedicled muscleap in two cases.

Systematic antibiotic prophylaxis was administeredeginning with debridement, associating beta-lactam andentamicin administered intravenously for 4 days followedy the association of amoxicillin and clavulanic acid per osor approximately 3 weeks until the flap had healed. Dor-al flexion of the talocrural joint was treated with physicalherapy. For the seven cases operated for septic nonunionith resection of osteitic bone, an intravenous vancomycin

reatment was initiated and replaced by a double antibioticherapy adapted to the bacteria found for at least 3 months.

The second stage of bone reconstruction occurred a meanmonths (range, 2—6 months) after the first stage. Oneatient had to be reoperated for an infection between thewo procedures. The nail was changed and the reconstruc-ion stage took place normally after prolonged intravenousntibiotic therapy. In all cases, bone grafting was decidedfter complete healing of the soft tissues and normalizationf the inflammatory biological constants. After bone har-esting from the two anterosuperior iliac crests (ten cases)r the four crests (two cases) with the posterosuperior crestsfor substantial bone loss), the site was initiated at the edge

f the flap, incising longitudinally the self-induced mem-rane to extract the pieces of cement by fragmentation.he cancellous bone grafts were then packed into the cav-

ty bordered by the membrane around the nail. In four cases,

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing 551

Table 1 Patients.

Case Age Sex Gustiloclassification

Time from injuryto 1st stage

Soft tissueprocedures

Weight-bearingafter 2nd stage

Postoperativeinfection

Bone defect(cm)

Follow-up(months)

1 18 M Closed 6 days LMF 4.5 + 15 942 68 F IIIb 45 days FMF 4 − 12 263 26 M IIIc 4 months FMF 7 − 10 474 61 M IIIc 3 months FMF 5 − 6 375 74 M II 5 months LMF 3 + 9 356 36 M IIIb 19 days FMF 5 − 6 617 38 M IIIb 6 months FMF 3 + 5 848 28 M III b Emergency 0 3 − 10 169 32 F II 1 month FMF 3 − 6 1210 40 M IIIc 2 months FMF 3 − 6 1211 43 M IIIa 2 months FMF 5 + 11 3812 24 M I 5 months FMF Failure + 8 12

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LMF: local muscle flap (one case of flexor digitorum muscle and ocases of anterior serratus, two cases of rectus abdominis muscles

tricalcium phosphate bone substitute was added to the graftmaterial. The graft was not packed against the fibula, as inthe intertibiofibular graft technique.

Results

Table 1 summarizes the patient data.The mean follow-up was 39.5 months (range,

12—94 months). Patients resumed weight-bearing a mean

4 months (range, 3—7 months) after the second stage. Boneunion was considered acquired at the last follow-up in allcases except for one patient, in whom infection occurred inthe weeks following bone grafting. A septic osteonecrosisfocus on the fixator pins had not been recognized during

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Figure 1 Case no. 3. a: preoperative X-ray (Gustilo IIIc fracture);sequestrum covered with ischemic cutaneous tissue in the first stagsecond stage); f: X-ray after removal of the material; g, h: last follo

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se of lateral fibularis brevis muscle); FMF: free muscle flap (twosix cases of latissimus dorsi muscle).

ebridement. After new debridement, including removalf the grafts, a modified Ilizarov bone transport techniqueas performed on the nail in place. In another patient, aail fracture in the 13th month required changing the nailith no new complications at 25 months of follow-up.

In the ten other cases, union was obtained with the nail inlace (Fig. 1), despite progression with scattered late infec-ious complications in four cases. These four cases of osteitisresented no rupture of bone continuity. Two infections thatrupted at 8 and 24 months required changing the nail fol-

owed by prolonged antibiotic therapy, which apparentlyllowed healing and union with 1 and 2 years of follow-upn the two cases. Two other infections occurred during thend year after reconstruction and were treated medically,ne successfully and the other not, since intermittent fistula

b: immediate postoperative X-ray; c: debridement of a bonee; d: second stage; e: integration of the graft (6 months afterw-up at 47 months.

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ersisted. This last patient now walks with a cane for morehan 1 km, at 35 months of follow-up. His precarious healths well as this acceptable functional result have motivatedim not to reoperate.

At the last follow-up, the patients walked without pain,ith a symmetrical gait angle and an aligned tibia, witho length discrepancy. The talocrural joint showed reducedobility values compared to the opposite side in six cases,ith two cases of painful equinus that were treated withchilles tendon lengthening. In three patients, the nailas removed to allow cortex thickening, with no resultingeformity or secondary fracture 6, 19, and 43 months afteremoving the material.

iscussion

he initial series reported by Masquelet et al. [5], whichncluded 27 cases of bone loss in the leg, manifestedhree types of complication: amputation, infection, and lateecondary fracture of the reconstituted segment. Two ampu-ations were necessary because of vascular complicationsthrombosis of arterial bypass) or because of associatedesions in the corresponding foot. They therefore do noteflect poorly on the method. However, they underscorehe importance of a careful examination of the function-lity of the foot before initiating a long surgical programassociated fractures and sensitivity of the correspondingoot). Similarly, in the three cases reported by Pelissiert al. [6], an amputation was necessary because of poorlood supply to the foot. In our series, no amputation wasequired and the two cases of residual equinus were recu-erated by a simple Achilles tendon lengthening procedure.oon et al. [8] reported an observation of the Masquelet

echnique on a nail for a tibial bone defect measuring0 mm at its smallest axis. The authors used a cementith an antibiotic (imipenem for Woon et al. and gentam-

cin for our study) and postoperative intravenous antibioticherapy.

Infection is undoubtedly the main complication.asquelet et al. reported five early recurrences of infectionetween the two stages: four were treated by repeatingebridement and placing a spacer and one case continuedo present chronic osteitis. Use of a nail does not seemo cause more severe infectious complications than usinghe external fixator, but they occur later. Four of the fiveate infectious complications in our series were controlledither by changing the nail or by prolonged antibioticherapy, without changing methods. As in Masquelet’series, one patient remained a carrier of chronic osteitisith acceptable function. Hyperbaric oxygen therapy is a

ignificantly effective adjuvant in cases of crushing injuryccording to Bouachour et al. [9].

The use of foreign bodies with antibiotic therapy wasvaluated for tibial bone loss with sepsis. McKee et al.10] used a bone substitute with tobramycin for 15 casesf external fixator osteosynthesis. All the patients achieved

one union, but three secondary fractures appeared at 3,8, and 22 months. Hutson et al. [11] filled the bone lossith gentamicin cement beads and applied the Ilizarovone transport technique. Alternatively, Masquelet et al.ecommended using a spacer without antibiotic and a per

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T. Apard et al.

s antibiotic prophylaxis limited to 7 days, so that annfection related to insufficient debridement would not beasked. It seems that the quality of the initial debridement,

lthough difficult to quantify, is the main factor of prognosis.epeated debridement is sometimes necessary; antibioticherapy should only be considered as additional treatmentor complete debridement. It is possible that use of gentam-cin cement in our series masked insufficient debridement,hich should have been revised earlier, explaining the high

ate of late infections, which, more numerous than in theeries reported by Masquelet et al. (5), had the disadvan-age of causing graft loss in one case, which is not the casef early infections occurring between the two stages. How-ver, the use of the intramedullary nail eliminated all localnfections on pins related to poor tolerance of the fixatorver the long term.

Stress fractures appeared late and were the third sourcef complication in this technique. Masquelet et al. reportwo cases occurring 2 years after reconstruction, beforeomplete corticalization of the reconstructed bone, whichequires several years. The intramedullary nail works as autor protecting bone reconstruction, but better flexibilityf the material (a titanium nail) could favor bone remodel-ng. The case of nail fracture in our series did not involve

repeated fracture but undoubtedly unrecognized asepticonunion, which we were able to treat with new nailing.inally, the three patients whose nail was removed have notresented late fracture.

From the mechanical point of view, intramedullary nail-ng allows earlier weight-bearing and has the advantage ofligning the leg bones. Stabilization therefore seems bet-er than with the external fixator, particularly in casesf substantial bone loss. Filling within the center ofhe self-induced membrane reduces the quantity of graftaterial necessary to fill the space left empty by the

pacer. However, radiological evaluation of bone union isore difficult because the metal can hide partial continu-

ty.Use of the locking nail assumes preservation of distal

nd proximal bone segments long enough to allow good-uality locking. However, the advent of nails with lockingoles very close to their ends (Expert, Synthès® nails, usedn one patient in this series) should extend this technique’seld of application, without resorting to fixators bridginghe adjacent joints.

onclusion

he self-induced membrane technique with cancellous auto-raft according to Masquelet et al. [5] is a reliable butong technique, requiring 6 months without weight-bearingn its initial description. It is facilitated by the use of anntramedullary stabilization nail, which can be implantedn the first stage. Infection remains the main complication,ccurring in a large number of cases, but its severity seemsimited and does not delay treatment nor compromise the

esult if it is treated early. In this respect, the infectionsn our series occurred later than in the Masquelet et al.eries, perhaps warranting the use of an acrylic spacer with-ut addition of antibiotics so as not to mask any effects ofncomplete debridement.

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Two-stage reconstruction of post-traumatic segmental tibia

Conflicts of interest

None.

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