Induced Membrane Technique for Aseptic Recalcitrant Nonunion of the Femur: A Case Report
Abstract
In aseptic recalcitrant nonunion, failure of bone healing coexists with malalignment and limb length discrepancy. There is still no consensus on the management of these cases. We present the case of a 53-year-old man with aseptic recalcitrant nonunion of the femur treated with the induced membrane technique. He had a history of a closed fracture of the right distal femur (AO 33-A3.3) and two previous surgeries at another institution. He presented with a limb length discrepancy of 3.1 cm, 6° of varus malalignment in the coronal plane, and 8° of internal rotation. After removal of the previous implant and radical debridement, the bone defect measured 4.2 cm. Stabilization was achieved with a retrograde intramedullary nail, and the defect was filled with polymethylmethacrylate cement mixed with vancomycin. In the second stage, the cement was removed, and the defect was filled with a mixture of autograft and allograft. Bone union was confirmed six months after treatment initiation, with filling of the defect and correction of the deformities. Conclusion: The induced membrane technique is a viable option for treating bone defects resulting from aseptic recalcitrant nonunion of the femur.Downloads
References
Vandekarr MF, Ruppenkamp JW, Vanderkarr M, Holy CE, Blauth M. Risk factors and healthcare costs associated
with long bone fracture non-union: a retrospective US claims database analysis. J Orthop Surg Res 2023;18(1):745. https://doi.org/10.1186/s13018-023-04232-3
Weir JC, Osinga R, Reid R, Roditi A, Duncan MacLean A, Lo SJ. Free vascularized medial femoral condyle periosteal flaps in recalcitrant long bone non-union: a systematic review. Arch Orthop Traum Surg 2020;140(11):1619-31. https://doi.org/10.1007/s00402-020-03354-1
Phillips MR, Harrison A, Metha S, Nolte PA, Bhandari M, Zura R. A scoping review of operative and non-invasive
management in the treatment of non-unions. Injury 2022;53(12):3872-8. https://doi.org/10.1007/s00402-020-03354-1
Nicholson JA, Makaram N, Simpson A, Keating JF. Fracture nonunion in long bones: a literature review of risk
factors and surgical management. Injury 2021;52(Suppl 2):S3-3S11. https://doi.org/10.1016/j.injury.2020.11.029
Ring D, Barrick WT, Jupiter JB. Recalcitrant nonunion. Clin Orthop Relat Res 1997;(340):181-9.
https://doi.org/10.1097/00003086-199707000-00023
Ma CH, Chiu YC, Tu YK, Yen CY, Wu CH. Three-stage treatment protocol for recalcitrant distal femoral nonunion.
Arch Orthop Trauma Surg 2017;137(4):489-98. https://doi.org/10.1007/s00402-017-2634-x
Jiang Y, Wang X, Huang W, Zhu Y, Zhang K, Feng D. A novel bone graft technique combined with plating for
aseptic recalcitrant long bone nonunion. BMC Musculoskelet Disord 2022;23(1):873. https://doi.org/10.1186/s12891-022-05830-8
Ma CH, Chiu YC, Tsai KL, Tu YK, Yen CY, Wu CH. Masquelet technique with external locking plate for recalcitrant distal tibial nonunion. Injury 2017;48(12):2847-52. https://doi.org/10.1016/j.injury.2017.10.037
Paniagua AR, Cunningham DJ, LaRose MA, Morriss NJ, Gage MJ. Psychological resilience as a predictor of opioid
consumption after orthopaedic trauma. Injury 2022;53(6):2047-52. https://doi.org/10.1016/j.injury.2017.10.037
Wu CC. Modified retrograde-locked nailing for aseptic femoral supracondylar nonunion with severe osteoporosis in elderly patients. J Trauma 2011;71(2):26-30. https://doi.org/10.1097/TA.0b013e3181f64ab1
Amorosa LF, Jayaram PR, Wellman DS, Lorich DG, Helfet DL. The use of the 95-degree-angled blade plate in
femoral nonunion surgery. Eur J Orthop Surg Traumatol 2014;24(6):953-60. https://doi.org/10.1007/s00590-013-1267-1
Ali F, Saleh M. Treatment of distal femoral nonunions by external fixation with simultaneous length and alignment correction. Injury 2002;33(2):127-34. https://doi.org/10.1016/s0020-1383(01)00032-8
Özdemir A, Osabasi E, Eravsar E, Safali S, Acar MA. Treatment of recalcitrant femur nonuinion with pedicle
corticoperiostal medial femoral condyle flap. Sci Rep 2023;13(1):202326. https://doi.org/10.1038/s41598-023-47432-x
Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010;41(1):27-37. https://doi.org/10.1016/j.ocl.2009.07.011
Masquelet AC. Induced membrane technique: Pearls and pitfalls. J Orthop Trauma 2017;31(Suppl 5):S36-S38.
https://doi.org/10.1097/BOT.0000000000000979
Giannoudis PV, Harwood PJ, Tosounidis T, Kanakaris NK. Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes. Injury 2016;47(Suppl 6):S53-S61.
https://doi.org/10.1016/S0020-1383(16)30840-3
Mi M, Papakostidis C, Wu X, Giannoudis PV. Mixed results with the Masquelet technique: A fact or a myth? Injury 2020;51(2):132-5. https://doi.org/10.1016/j.injury.2019.12.032
Masquelet AC, Gaillard J, Boutroux P, Beauthier-Landauer V, Cambon-Binder A. The wrapping-induced membrane technique for treating recalcitrant nonunions. Ann Chir Plast Esthet 2020;65(4):320-5.
https://doi.org/10.1016/j.anplas.2020.04.004.
Pesciallo CA, Garabano G, Dainotto T, Ernst G. Masquelet technique in post-traumatic infected femoral and tibial segmental bone defects. Union and reoperation rates with high proportions (up to 64%) of allograft in the second stage. Injury 2021;52(11):3471-7. https://doi.org/10.1016/j.injury.2021.08.031
Weber BG, Cech O. Pseudoarthrosis. Pathophysiology, biomechanics, therapy, results. Berna: Huber; 1976.
Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFayen I, Scarborough M, et al. Fracture-related
infection: A consensus on definition from an international expert group. Injury 2018;49(3):505-10.
https://doi.org/10.1016/j.injury.2017.08.040
Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res
;(414):7-24. https://doi.org/10.1097/01.blo.0000088564.81746.62
Ganz R, Horowitz K, Leunig M. Algorithm for femoral and periacetabular osteotomies in complex hip deformities. Clin Orthop Relat Res 2010;468(12):3168-80. https://doi.org/10.1007/s11999-010-1489-z
Wiss DA, Garlich J, Hasmi S, Neustein A. Risk factors for development of recalcitrant femoral nonunion: A single surgeon experience in 122 patients. J Orthop Trauma 2021;35(12):619-25. https://doi.org/10.1097/BOT.0000000000002276
Wiss DA, Garlich J, Sherman R. Healing the index tibial nonunion: risk factors for development of a recalcitrant
nonunion in 222 patients. J Orthop Trauma 2021;35(9):e316-e321. https://doi.org/10.1097/BOT.0000000000002060
Ayouba G, Lemonne F, Kombate NK, Bakriga B, Yaovi Edem J, André-Pierre Max U. Interest of nailing associated with the Masquelet technique in reconstruction of bone defect. J Orthop 2019;20:228-31.
https://doi.org/10.1016/j.jor.2019.12.014
Garabano G, Pesciallo CA. Definitive fixation in the first stage of induced membrane technique for septic segmental bone defects. Why not? J Clin Orthop Trauma 2022;37:102089. https://doi.org/10.1016/j.jcot.2022.102089
Kubiak EN, Beebe MJ, North K, Hitchcock R, Potter MQ. Early weight bearing after lower extremity fractures in
adults. J Am Acad Orhop Surg 2013;21(12):727-38. https://doi.org/10.5435/JAAOS-21-12-727
Natoli RM, Marinos DP, Montalvo RN, Degani Y, Ochenjele G, Griffith C, et al. Poor agreement between nextgeneration DNA sequencing and bacterial cultures in orthopaedic trauma procedures. J Bone Joint Surg Am
;104(6):497-503. https://doi.org/10.2106/JBJS.21.00785
Nau C, Seebach C, Trumm A, Schible A, Kontradowitz K, Meier S, et al. Alteration of Masquelet’s induced
membrane characteristics by different kinds of antibiotic-enriched bone cement in a critical size defect model in the rat’s femur. Injury 2016;47(2):325-34. https://doi.org/10.1016/j.injury.2015.10.079
Andrzejowski P, Giannoudis PV. The diamond concept for long bone non-union management. J Orthop Traumatol 2019;20(1):21. https://doi.org/10.1186/s10195-019-0528-0
Manuscript acceptance by the Journal implies the simultaneous non-submission to any other journal or publishing house. The RAAOT is under the Licencia Creative Commnos Atribución-NoComercial-Compartir Obras Derivadas Igual 4.0 Internacional (CC-BY-NC.SA 4.0) (http://creativecommons.org/licences/by-nc-sa/4.0/deed.es). Articles can be shared, copied, distributed, modified, altered, transformed into a derivative work, executed and publicly communicated, provided a) the authors and the original publication (Journal, Publisher and URL) are mentioned, b) they are not used for commercial purposes, c) the same terms of the license are maintained.
In the event that the manuscript is approved for its next publication, the authors retain the copyright and will assign to the journal the rights of publication, edition, reproduction, distribution, exhibition and communication at a national and international level in the different databases. data, repositories and portals.
It is hereby stated that the mentioned manuscript has not been published and that it is not being printed in any other national or foreign journal.
The authors hereby accept the necessary modifications, suggested by the reviewers, in order to adapt the manuscript to the style and publication rules of this Journal.
