Distal Femoral Non-Union in Gunshot Wounds; Masquelet Technique Management and Literature Review

Abstract

Introduction Gunshot-related open fractures are at risk for significant bone loss. Consolidation is unlikely in defects larger than 2 cm. The induced membrane technique (IMT) results in the formation of a membrane to facilitate consolidation. We present two cases of gunshot-related open fracture progressing with infected non-union and bone defects and their subsequent management with IMT.

Cases We present two cases of open fracture of the distal femur secondary to a gunshot wound. Initially, the two cases underwent external fixation followed by an intramedullary nail (IMN) placement. Both progressed with infected non-union and a 4-cm bone defect. IMT resulted in infection control and fracture consolidation.

Discussion IMT was a successful salvage surgery for bone defects secondary to an infected femoral non-union. Managing bone defects is challenging due to infection, soft tissue loss, bone gap, and fracture healing potential. IMT is an attractive alternative for treating bone defects bigger than 2 cm since the repair is independent of the defect size and allows infection control.

Conclusion IMT is an effective salvage technique for the management of bone defects caused by gunshots. It allows limb salvage and comprehensively manages the several aspects requiring consideration in these cases.

Keywords

induced membrane technique - bone defect - infected non-union

Publication History

Received: 10 July 2023

Accepted: 05 October 2023

Article published online:
26 December 2023

• Bibliografía

• 1 Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury 2007; 38 (Suppl. 04) S3-S6 DOI: 10.1016/s0020-1383(08)70003-2.
• 2 Keating JF, Simpson AH, Robinson CM. The management of fractures with bone loss. J Bone Joint Surg Br 2005; 87 (02) 142-150 DOI: 10.1302/0301-620x.87b2.15874.
• 3 Giannoudis PV. Treatment of bone defects: Bone transport or the induced membrane technique?. Injury 2016; 47 (02) 291-292 DOI: 10.1016/j.injury.2016.01.023.
• 4 Klein C, Monet M, Barbier V. et al. The Masquelet technique: Current concepts, animal models, and perspectives. J Tissue Eng Regen Med 2020; 14 (09) 1349-1359 DOI: 10.1002/term.3097.
• 5 Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis PV. Bone Repair Using the Masquelet Technique. J Bone Joint Surg Am 2019; 101 (11) 1024-1036 DOI: 10.2106/JBJS.18.00842.
• 6 Rao N, Ziran BH, Lipsky BA. Treating osteomyelitis: antibiotics and surgery. Plast Reconstr Surg 2011; 127 (Suppl. 01) 177S-187S DOI: 10.1097/PRS.0b013e3182001f0f.
• 7 Lasanianos NG, Kanakaris NK, Giannoudis PV. Current management of long bone large segmental defects. Orthop Trauma 2010; 24 (02) 149-163 DOI: 10.1016/j.mporth.2009.10.003.
• 8 Marais LC, Ferreira N. Bone transport through an induced membrane in the management of tibial bone defects resulting from chronic osteomyelitis. Strateg Trauma Limb Reconstr 2015; 10 (01) 27-33 DOI: 10.1007/s11751-015-0221-7.
• 9 De los Santos MFA, Ceballos SJA, Hernández FE, Sierra PM, Herrera CZV. Técnica de Masquelet en no unión atrófica de tibia con osteomielitis crónica, su descripción. Acta Med Grupo Ángeles 2021; 19 (02) 280-284 DOI: 10.35366/100456.
• 10 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 meta-analysis. Bone Joint J 2013; 95-B (12) 1673-1680 DOI: 10.1302/0301-620X.95B12.32385.
• 11 Aronson J, Harrison BH, Stewart CL, Harp Jr JH. The histology of distraction osteogenesis using different external fixators. Clin Orthop Relat Res 1989; (241) 106-116
• 12 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) 3471-3477 DOI: 10.1016/j.injury.2021.08.031.
• 13 Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res 1990; (250) 8-26
• 14 Shen Z, Lin H, Chen G. et al. Comparison between the induced membrane technique and distraction osteogenesis in treating segmental bone defects: An experimental study in a rat model. PLoS One 2019; 14 (12) e0226839 DOI: 10.1371/journal.pone.0226839.
• 15 Ashman O, Phillips AM. Treatment of non-unions with bone defects: which option and why?. Injury 2013; 44 (Suppl. 01) S43-S45 DOI: 10.1016/S0020-1383(13)70010-X.
• 16 Alford AI, Nicolaou D, Hake M, McBride-Gagyi S. Masquelet's induced membrane technique: Review of current concepts and future directions. J Orthop Res 2021; 39 (04) 707-718 DOI: 10.1002/jor.24978.
• 17 Bafor A. Distraction osteogenesis: A review of the literature. Nigerian Journal of Orthopaedics and Trauma 2020; 19 (01) 1 https://link.gale.com/apps/doc/A631007781/HRCA?u=anon~80fd8424&sid=googleScholar&xid=cd9bf3a
• 18 Klaue K. . Knothe, et al. Biological implementation of autologous foreign body membranes in corticalization of massive cancellous bone grafts. Trans Orthopaedic Trauma Assoc, 1998
• 19 Morelli I, Drago L, George DA, Gallazzi E, Scarponi S, Romanò CL. Masquelet technique: myth or reality? A systematic review and meta-analysis. Injury 2016; 47 (Suppl. 06) S68-S76
• 20 Taylor BC, French BG, Fowler TT, Russell J, Poka A. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg 2012; 20 (03) 142-150 DOI: 10.5435/JAAOS-20-03-142.