Injury, Int. J.
Care Injured 47 (2016) 291–292
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Editorial
Treatment of bone defects: Bone transport or the induced membrane
technique?§
The aetiology of bone defects can be multifactorial including,
acute bone loss, bone debridement following infection, non-union
or avascular bone secondary to previous radiotherapy and tumor
excision [1]. Their management remains challenging for both the
surgeon and the patient and in spite of advances made in every
discipline of medicine including tissue engineering the incident of
amputation remains high [2]. Of interest, in the past and prior to
the introduction of microsurgical techniques and free tissue
transfers, amputation was the ‘only solution’.
In the mid 1950s the concept of distraction osteogenesis and
bone transport was introduced by Ilizarov revolutionising the
treatment of bone defects [3]. Since then, many limbs with severe
injuries have been salvaged with satisfactory outcomes. Nonethe-
less, the treatment course is usually lengthy, associated with
setbacks, and the cost of treatment can be enormous. The cost
however, is usually not an issue as non-one and particularly the
patient himself would question the cost incurred to retain a
reasonably functional limb. Noteworthy, in some societies,
spending a huge amount of money for even retaining a
dysfunctional limb would be acceptable.
Despite the overall acceptance of the bone transport technique,
some patients physically and mentally are not able to tolerate the
length of treatment and its associated complications. In these
circumstances options left to consider for treatment include
megaprosthesis, particularly for metaphyseal defects, free fibula
vascularised transfer, titanium cages loaded with autologous,
allogenic or synthetic bone or combination of all; and obviously the
so called one ‘shot surgery’, amputation.
Lately, another solution to this difficult clinical problem has
become available with the introduction of the induced membrane
technique by Masquelet [4]. This technique has initiated a new era
in the management of bone defects [5]. It involves two stages.
Firstly, following soft tissue reconstruction (if it is required), a
cement spacer (PMMA) is implanted at the site of the bone defect.
The local foreign body reaction encourages the formation of a
pseudoperiosteum (membrane) tissue layer within a 4 to 6-week
period. This membrane has been found to be very angiogenic,
possessing inductive properties for bone repair and containing
abundant number of osteoprogenitor cells [6].
Removal of the cement spacer and implantation of autologous
or allogeneic bone graft in the site of the defect is the hallmark of
§
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article. No funds
were received in support of this study.
http://dx.doi.org/10.1016/j.injury.2016.01.023
0020–1383/ß 2016 Published by Elsevier Ltd.
the second stage. Other biological based therapies applied at the
site of the defect include combination of graft materials, the so
called ‘diamond concept’ approach [7,8]. The bone graft placed at
the defect area is well contained by the induced membrane layer.
The membrane assists into the neo-vascularisation of the graft,
host acceptance and integration and restoration of bone continuity
and function of the affected extremity. Overall, one could argue
that the induced membrane has gained great acceptance and its
application has expanded worldwide. In addition, it has generated
great scientific interest and has been the focus of many research
teams to have its molecular profile decrypted.
Manuscripts reporting on the effectiveness, successes, failures
and outcomes of both techniques are available with variable
results [3,9–14]. It is clear that both techniques can be effective
assuming that the principles of treatment are well adhered to and
any developed complications are well managed. However, the
question remains which technique should be used for what kind of
patient? How do I decide? How do I consent the patient and
provide him with a detailed representation of the advantages and
disadvantages (complications) of each technique?
For instance, bone transport is associated with painful ongoing
stimuli, pin site infections, broken wires, readmissions and
reoperations, social implications of keeping the frame for several
months if not year(s), failure of bone consolidation, nonunion of
the docking site, loss of alignment, more outpatient visits and more
radiation exposure. With regard to the social implications, patients
should be informed of such family issues as: clothing wearing
limitations, being unable to sleep with their partners, implications
in their sex life, negotiating going through narrow spaces, daily
commitment to look after the apparatus (distraction phase),
frequent pin site care and prescription of course of antibiotics at
not infrequent intervals, and frequent prescription of narcotics to
say the least. Obviously, one of the major argument of choosing
bone transport is early weightbearing. However, is this the case? It
is common knowledge that one of the limitations of frames is ankle
stiffness/loss of ankle movement. Long term, chronic skin irritation
from scarring from the fine wire sites is also another issue to
consider.
With regard to the induced membrane technique, such
parameters should be discussed with patients as the two stage
component of the technique, the subsequent need of harvesting of
a large volume of autologous bone graft (RIA has provided a
solution to this issue) [15], failure of the graft to re-vascularise and
to consolidate thus the requirement of further surgery, failure of
metalwork and loss of alignment. Moreover, there is a possibility
of residual infection to be present and noted during the second
292 Editorial / Injury, Int. J. Care Injured 47 (2016) 291–292
stage, a finding that might necessitate further debridement and
going back to stage one of the technique. However, the social
implications previously discussed with the frames are not so
intrusive with the metal work being placed internally. With regard
to the issue of early weight being, for diaphyseal bone defects the
use of an intramedullary nail can facilitate early weight bearing,
being a load sharing device, whereas, for metaphyseal defects a
plating option can be supported with an external splint for several
weeks.
Another important issue when discussing what technique to
choose is the timing required for a successful bone repair response.
For instance, defects up to 25 cm have been reported to have fully
consolidated with the masquelet technique within 12 months.
Such a defect to be repaired with bone transport would require on
average 1 cm per month, thus at least double the amount of this
time scale. In fact, that amount of defect would require bifocal
transport and even then pending on the extent of metaphyseal
bone available, bone transport might not be feasible.
So what technique should we choose when we manage this
difficult cohort of patients? Bone transport or the induced
membrane? In my opinion these two techniques should not be
competing with each other. Instead, they should be complimenta-
ry. Obviously, some surgeons may have acquired excellent skills in
one of them and naturally, this is what they would offer to the
patient. This is quite acceptable as long as the patient is informed in
detail about all the issues discussed above and becomes completed
aware what each road path involves.
In the future, comparative studies between the two techniques
would provide us with more information to understand and
appreciate better the challenges to overcome, both surgery and
patient related. Only then we would be in a position to make the
right choice of technique for the right patient.
References
[1] Kanakaris NK, Tosounidis TH, Giannoudis PV. Surgical management of infected
non-unions: an update. Injury 2015;46(November (Suppl 5)):S25–32.
[2] Giannoudis PV, Calori GM, Bégué T, Schmidmaier G. Tissue loss and bone
repair: time to develop an international strategy? Injury 2015;46(December
(Suppl 8)):S1–2.
[3] Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in the
treatment of long bone defects of the lower limbs: effectiveness, complications
and clinical results; a systematic review and metaanalysis. Bone Joint J
2013;95-B:1673–80.
[4] Masquelet AC, Fitoussi F, Begue T, et al. Reconstruction of the long bones by the
induced membrane and spongy autograft. Ann Chir Plast Esthet 2000;45:
346–53.
[5] Chadayammuri V, Hake M, Mauffrey C. Innovative strategies for the manage-
ment of long bone infection: a review of the Masquelet technique. Patient Saf
Surg 2015;9:32.
[6] Cuthbert RJ, Churchman SM, Tan HB, McGonagle D, Jones E, Giannoudis PV.
Induced periosteum a complex cellular scaffold for the treatment of large bone
defects. Bone 2013;57(December (2)):484–92.
[7] Giannoudis PV, Gudipati S, Harwood P, Kanakaris NK. Long bone non-unions
treated with the diamond concept: a case series of 64 patients. Injury
2015;46(December (Suppl 8)):S48–54.
[8] Moghaddam A, Zietzschmann S, Bruckner T, Schmidmaier G. Treatment of
atrophic tibia non-unions according to ‘diamond concept’: results of one- and
two-step treatment. Injury 2015;46(October (Suppl 4)):S39–50.
[9] Olesen UK, Eckardt H, Bosemark P, Paulsen AW, Dahl B, Hede A. The Masquelet
technique of induced membrane for healing of bone defects. A review of
8 cases. Injury 2015;46(December (Suppl 8)):S44–7.
[10] Scholz AO, Gehrmann S, Glombitza M, Kaufmann RA, Bostelmann R, Flohe S,
Windolf J. Reconstruction of septic diaphyseal bone defects with the induced
membrane technique. Injury. 2015;46(October (Suppl 4)):S121–4.
[11] Ronga M, Ferraro S, Fagetti A, Cherubino M, Valdatta L, Cherubino P. Masquelet
technique for the treatment of a severe acute tibial bone loss. Injury
2014;45(December (Suppl 6)):S111–5.
[12] Bosemark P, Perdikouri C, Pelkonen M, et al. The Masquelet induced mem-
brane technique with BMP and a synthetic scaffold can heal a rat femoral
critical size defect. J Orthop Res 2015;33:488–95.
[13] Christou C, Oliver RA, Yu Y, et al. The Masquelet technique for membrane
induction and the healing of ovine critical sized segmental defects. PLoS ONE
2014;9:e114122.
[14] Bieler D, Franke A, Willms A, et al. Masquelet technique for reconstruction of
osseous defects in a gunshot fracture of the proximal thigh – a case study. Mil
Med 2014;179:e1053–58.
[15] Cox G, Jones E, McGonagle D, Giannoudis PV. Reamer-irrigator-aspirator
indications and clinical results: a systematic review. Int Orthop 2011;35(July
(7)):951–6.
Peter V. Giannoudis MB, BSc, MD, FACS, FRCS(Eng)a,b,*
a
Professor, Academic Department of Trauma & Orthopaedics,
School of Medicine, University of Leeds, Leeds, UK
b
NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital,
LS7 4SA Leeds, West Yorkshire, Leeds, UK
*Corresponding author at: Academic Department Trauma &
Orthopaedic Surgery, School of Medicine,
University of Leeds, Leeds, UK. Tel.: +44 113 3922750;
fax: +44 113 3923290
E-mail address: pgiannoudi@aol.com (P.V. Giannoudis).