The document discusses the Masquelet technique, a two-stage procedure for treating bone defects and non-unions. In the first stage, radical debridement is performed followed by placement of an antibiotic-loaded cement spacer to form an induced membrane. In the second stage 6-8 weeks later, the membrane is preserved while removing the spacer and filling the defect with bone graft for reconstruction. Studies reported successful outcomes using this technique for various bone defects up to 25cm in length. Key factors for success include thorough debridement, maintaining the induced membrane, adequate stabilization and soft tissue management.

1. Dr. Shubhanshu
Orthopedics Surgeon

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