1. The document compares the Ilizarov technique and Masquelet technique for treating infected nonunions of the tibia. 2. The Masquelet technique is a two-stage procedure that uses a PMMA spacer to induce the formation of a vascularized membrane, which is then used to support bone grafting. 3. The Ilizarov technique uses ring external fixators to gradually transport bone and fill gaps, allowing for weight bearing and correction of deformities during the process.

1. COMPARISON BETWEEN ILIZAROV
AND MASQUELET TECHNIQUE IN
INFECTIVE NONUNION TIBIA

2. NON UNION
• “Established when a minimum of 9 months has
elapsed since injury and the fracture shows no
visible progressive signs of healing for 3 months”.
• The diagnosis of nonunion should not be made
until clinical or radiographic evidence is noted that
healing has ceased or that union is highly unlikely.

5. INFECTIVE NONUNION
• When using CBC (white blood cells [WBCs]),
ESR, and the positive predictive value when all
three values are positive is 100% .
• The negative predictive value when all three
laboratory values are negative is 81.6%

7. TYPES
• Nonunions are classified based on location,
presence or absence of infection, and etiology:
• ■ Epiphyseal, metaphyseal, or diaphyseal
• ■ Septic or aseptic
• ■ Hypertrophic, oligotrophic, or atrophic .
• ■ Pseudarthrosis

9. • The requirements for successful nonunion
treatment are:
•Biomechanical stability.
•Biologic vitality of the bone.

10. FORMS OF NONUNION TREATMENT
• Bone grafting(Cortical and cancellous).
• External fixation.
• Noninvasive options like low intensity
ultrasound,electromagnetic
stimulation,extracorporeal shockwave therapy.
• Amputation.
• Membrane induced technique.

11. APPROACHES TO NONUNION
• The first is the conventional, or classic, method
used for many decades.
• The second is the active method.

12. • The objectives of the conventional method are :
1)To convert an infected and draining nonunion
into one that has not drained for several months.
2)To promote healing of the nonunion by bone
grafting.
3) Debridement is performed with removal of all
foreign, infected, or devitalized materials to
provide a vascular bed.

13. • The objective of the active method is :
1-To obtain bony union
2-Early and shorten the period of
convalescence and preserve motion in the
adjacent joints.

14. MASQUELET TECHNIQUE
• It does not regenerate bone but relies on
grafting, and may be done with external or
internal fixation.
• The two-phase treatment relies on the
production of a vascularized foreign-body
membrane to support bone grafts over three
times larger than the traditional maximum.
• Induced membrane favors revascularization and
consolidation of the bone graft.

15. PROPERTIES OF MEMBRANE
• Induced membrane is richly vascularised.
• High concentrations of BMP-2.
• VEGF, and TGF-β1 ,VWF,IL-6,8 were observed
within the induced membrane.
• The membrane thus functions to prevent soft
tissue protrusion in the bone defect site,
provides a scaffold for osteoconduction.

17. • PMMA spacer provide some stability in an
osseous defect situation.
• The body’s reaction to PMMA beads or a spacer
leaves a bioactive membrane, Masquelet
membrane.
• It can be 0.5 to 1mm thick and has been
described as both hyper-vascular and
impermeable.

18. • Different membrane characteristics can be
created by altering the spacer surface properties.
• Surgeons may unknowingly effecting membrane
formation via bone cement preparation
techniques.

19. Operative procedure
• This technique involves 2 surgeries, stage I and
stage II.
• Stage I surgery includes irrigation and
debridement of the infected soft tissue and bone,
along with fracture stabilization with external
fixators.

21. • Stage II surgery was performed after 4–6 weeks
of stage I surgery in the absence of any clinical
signs of infection.
• Stage II surgery included removal of the
cement-spacer, with preservation of the induced
membrane formed at the spacer surface and
filling the bony defect space with morselized iliac
crest bone graft.

26. • The spacer was always found to be
encapsulated by a thick glistening
membrane in all patients This induced
membrane was not adherent to the
underlying cement and bled when incised.
• it was mechanically competent and could
be reapposed without tension in all
patients.
• The spacer could be removed without
much difficulty and without causing any
damage to the induced membrane.

27. DEFECT FILLING
• Bone grafting amount varied in patients according
to defects of bone.
• Some unilateral,some bilateral others mixed like
bonegraft with G-bone in 1:1 proportions.
• Graft from reamer-irrigator-aspirator (RIA)
technique from ipsilateral femur.
• Some usedof BMPs with the bone graft .
• The defect should be completely filled but not
overstuffed. Once the defect was filled, the
biomembrane was closed with absorbable suture.

28. MECHANICAL STABILIZATION
• Intramedullary nailing.(Allows immediate
weight bearing)
• External fixator.
• Plating.

29. • Antibiotics were given for total duration of 6 to 8
weeks, from stage I surgery till the day of stich
removal, after stage II surgery.
• In cases where infection was suspected after first
surgery 3 weeks of iv and 5 weeks oral
antibiotics were given.

30. • Radiological and clinical evaluation was done for
all patients at every 6 weeks followup for first 6
months and every quarterly thereafter.
• Radiographically successive radiographs showed
regular integration and consolidation of the
bone graft.

31. • Clinically union was confirmed with absence of
abnormal mobility and absence of pain on
weight bearing.
• Radiological union was documented, when graft
gets consolidated within themselves in the
region of bone gap and unites with the host bone
at both the ends.

32. ADVANTAGES
• Treatment being easy, simple and lacks use of any
sophisticated instrumentations and investigation.
• It provides a treatment option that can overcome
the shortcomings and limitations of the available
methods of treatment.
• Easy to learn technique .
• Provides both effective and practical management
for the difficult gap nonunions with or without
infection and with or without accompanying soft
tissue defect.

33. DISADVANATGES
• The chief drawback of this technique is the need for
large amounts of bone graft.
• It is a two-stage procedure with the associated risks
of secondary anesthesia and hospitalization.
• Limited bone graft to harvest in very young
children. .
• Inability to correct residual limb length discrepancy
& deformities.
• To remain non weight bearing during the initial
treatment as the large bone gaps were weakly
immobilised with external fixators
• Thus weight bearing was started only when the graft
showed consolidation.

34. RIA GRAFT
• The RIA enables harvest of 60 to 80 cc of
marrow graft from the opposite femoral canal.
• RIA graft can have high harvest morbidity. It
may result in loss of large volumes of blood
during harvest.
• Lowering of 2 to 3 g of Hb levels are known after
RIA harvest.

39. • Classification of infected nonunions should have
prognostic value and help choose treatment.
ASAMI classification is commonly used.
• Infection is classified as active or dormant.

41. ILIZAROV BONE TRANSPORT
• Bone transport technique is one of the great
inventions of the 20th century.
• It enables filling up large gaps of bone, in many
instances without the need for bone grafting or
bone graft substitutes.
• Include ilizarov,LRS,Taylor spatial frame.

42. • Acute or subacute compression fills the bone gap
if it is less than 3 cm and larger gaps may be
filled by gradual compression.
• A fibulectomy allows acute compression of tibial
bone ends. Acute compression is followed by
lengthening.

43. The accordion manoeuvre consists of
several cycles of compression and
distraction at the regenerate site to
improve bone quality.

44. CAUSES OF POOR REGENERATE
FORMATION
• Loosening of pins.
• Persistent infection.
• Increased resistance of scarred posterior soft
tissues also leads to procurvatum at the
regenerate.
• Smokers and those on nonsteroidal anti-
inflammatory drugs.
• Hypovitaminosis D and anemia.
• Poor soft tissue cover leads to poor.

45. ADVANTAGES OF RING FIXATORS
• Even if mild infection persists, it will not cause
failure of the entire process as can happen with
the induced membrane technique.
• Regenerate is unaffected by any flare-up of
infection at the nonunion site.
• It is inexpensive physiologically and
economically.
• It allows equalization of limb length and
correction of deformities.

46. COMPLICATIONS
• Pin tract infection is the main complication.
• Grading and management were done as per Dahl’s
• Grade I – Normal pin site
• Grade II – Inflamed
• Grade III – Inflamed with serous discharge
• Grade IV – Inflamed with purulent discharge
• Grade V – Inflamed with osteolysis
• Grade VI – Inflamed with ring sequestrum.

47. • Fracture union and quality of regenerate were
assessed by taking X-rays on the basis of
Fernandez Esteve grading:
• Grade I– Empty space between two fragments
without radiopacity
• Grade II – Presence of cloud of bony callus
• Grade III – Presence of periosteal bridge in at
least one Diaphyseal wall in every X-ray
projection
• Grade IV– Presence of periosteal bridge in both
diaphyseal walls in every X-ray projection
• Grade V – Structural callus is seen.

48. CONCLUSION
• The main principles of treatment of infected
nonunions of the tibia are
• (1) Radical and thorough debridement,
• (2)Compression of nonunion by external fixation
with lengthening or bone transport,
• (3) Conversion to internal or hybrid fixation in
less severe infections, and
• (4) Augmentation of healing by bone grafting,
bone marrow injections, platelet concentrates,
and DBM.

51. • https://www.sciencedirect.com/science/article/
pii/S0020138317301973