masqulete technique induced membrane technique

1. Dr. Shubhanshu
Dr. Pushpendra

2.  The Concept of Induced Membrane for
Reconstruction of Long Bone Defects by Alain
C.Masquelet,Thierry Begue in Elsevier journal
2010
 Masquelet technique for the treatment of
bone defects:Tips-tricks and future directions
by Peter V. Giannoudis et al in Elsevier 2011
 Current Concepts Review - Bone Repair Using
the Masquelet Technique by Alain Masquelet
et al in JBJS journal 2019

3.  Masquelet technique for infected distal radius
fractures with gaps in paediatric age group by
John Mukhopadhaya, Janki Sharan Bhadani in
Elsevier 2021
 A case report of extensive segmental defect
of the humerus due to thermal necrosis
treated with Masquelet technique by John
Mukhopadhaya, Kumar Gautam, Janki Sharan
Bhadani in Elsevier 2021

5.  INTRODUCTION
 EFFECT OF THE INDUCED MEMBRANE
 INDICATIONS
 CONTRAINDICATIONS
 KEYS FOR BETTER OUTCOMES
 DRAWBACKS
 VARIOUS REPORT OUTCOMES

6.  Masquelet first described in 1986
 2 Steps procedure
for bone defect (upto25cm) and
non-union by induced membrane
osteogenesis

7. Induced membrane :
 Pseudosynovial membrane formed around
cement spacer due to foreign body
reaction(stage-1)
 Acts chamber around the bony defect to
contain the bone graft and stimulate bone
regeneration(stage-2)

8. A. Mechanical effects
◦ Cement spacer maintains the length of bone and
prevent soft tissue interposition
◦ Creates contained space for the placement of bone
graft
◦ Prevent the reabsortion of the bone graft in the
defects and remains non-adherent to cement
spacer
◦ Cement spacer may be used as a carrier for
antibiotics to achieve high local concentration of
antibiotics without systemic toxicity

9. B. Biological effects
◦ Membrane rich in type 1 collagen, fibroblasts and
myofibroblasts
◦ Highly vascular due to high concentration of VEGF
which promotes angiogenesis
◦ Increased levels of TGF-beta, BMP-2 which
promotes osteogenesis

10. Bone defects Secondary to
 Chronic osteomyelitis
 Traumatic bone loss
 Septic non-unions
 Aseptic non-unions
 Tumour excision

11.  Limb length discrepancy
 Soft tissue coverage not possible
 Graft unavailability

12. In First Stage:
 Radical infected soft tissue and bone
debridement
 PMMA cement spacer with or without
antibiotics at bone defect
 Limb stabilize with external/internal fixation
 Soft tissue reconstruction

13.  Thorough debridement and irrigation
 Edges of bone should be healthy with viable
bleeding
 Appropriate fixation of bone defect
 Meticulous pin site care
 Cement should be placed inside canal and
over edges
 Cement spacer loaded with or without
antibiotics

14.  Soft tissue envelop should have adequate
blood supply
 Good soft tissue coverage
 Wound closure must not be under tension

15. After Debridement
Punctate Bleeding at bony edges
Cement over the edges of bone
Maintain space of reconstruction

16.  Usually 6-8 weeks

17.  No evidences showing any relation in interval
duration between using external
fixatornailingplating in 1st stage.
 Clinical studies shows that using antibiotics
loaded cement spacer decrease infection
 In clinical study by Biau shown that Femur
(c/o Ewing Sarcoma) takes longer Interval
period than rest locations i.e 7 months

18. Mechanical stability using temporary external fixator

19. In Second stage:
 6-8 weeks later
 Cement spacer is carefully removed
 Formed “INDUCED MEMBRANE” is minimally
disturbed
 Defect is filled with morcellised cancellous
autologous bone graft(with additional bone
graft substitutes, 1:3)
 Fixation is mandatory for bone stabilization.

20.  Culture prior to administration of antibiotics
intraoperatively
 Membrane must be incised with caution
 Cement spacer removed with saw or
osteotome
 IM canal is prepared with hand reamers and
curette
 All non-vitals tissue must be removed

21.  Depending on size adequate volume of graft
material should be available
 Autologous bone graft from Iliac crest or
intramedullary canal by
Reamer/Irrigator/Aspirator(RIA)
 For large defect can be augmented with
allograft or bone substitute
 Bone graft material can be enhanced with
osteoprogenitor cells or osteoinductive
growth factors

22.  Graft material must be enclosed within
membrane
 Adequate mechanical stability
 Adequate soft tissue coverage
 Wound closure must not be under tension

23. Intraop- Induced Membrane
External fixator for temporary stabilization
of humerus with k-wire used in cement
mantle to prevent displacement of spacer

24. Elements of step 2

25. Bone graft with BMP-7 After 8 Month
X-Ray of Infected Non-Union

26. Tibial Fracture managed with Masquelet Technique

27.  Total cases: 127+2(pediatrics)
 Locations: Tibia(MC)-35
TibiaFemur-25
TibiaFemurHumerus-22
Femur- 1
Humerus- 2
Radius – 2 (pediatrics)
 Bony Defect length: 1-25cm

28.  1st Stage- External Fixator MC used(68)
- Nailing(22)
- Plating(1)
- Cast (2)
- External FixatorNailingPlating(25)

29.  6-8 weeks - 101
 14-16 weeks - 21
 11-13 week - 2
 5 week - 1
 7 month - 1

30. Union @ months No of Patients Infection Non Union
3 Month 1 - -
4 Month 34 5 4
5-6 Month 10 2 -
9 Month 48 2 1
12 Month 26 1 1
18 Month 1 - 1

31.  4 Pt having Stress Fracture
 1 Pt having decreased shoulder ROM
 2 Pt having Ankle Stiffness

34.  Two different interventions
 Availability of graft
- Limited
- Donor site morbidity
 Supplementary procedures for soft tissue
transfer

35.  Masquelet technique provides good
functional outcome in patients with severe
bone defect and non-union
 Meticulous debridement in stage one and
preservation of Induced Membrane in stage
two are key to this techniques

36.  Using antibiotics cement spacer decreases
further infection
 By using this technique can achieve functional
range of motion
 Autogenous bone graft helped in improving
the stability of fixation and reduced risk of
fixation failure