Advertisement

Induced Membrane Technique for the Treatment of Infected Forearm Nonunion: A Retrospective Study

Published:September 22, 2021DOI:https://doi.org/10.1016/j.jhsa.2021.06.019

      Purpose

      Infected forearm nonunion remains a challenge for the hand surgeon. Autologous bone grafting within an induced membrane following implantation of a cement spacer, also known as the Masquelet technique, is a procedure used for addressing segmental bone defects. This report summarized our experience using this technique to treat the infected forearm nonunion.

      Methods

      We retrospectively reviewed a series of 32 patients treated for infected forearm nonunion by the 2-stage Masquelet technique between 2009 and 2018. There was an infected nonunion of the ulna in 28 patients and an infected nonunion of the radius in 4 patients. All patients had undergone an average of 2.7 procedures before presenting at our institution. Treatment involved a staged procedure in which an antibiotic-impregnated cement spacer was implanted into the bone defect following debridement without internal fixation. It was left in place for 4–6 weeks, during which time a membrane formed around the cement spacer. In the second stage, the induced membrane was incised, and the cement spacer was removed. The defect was then filled with cancellous autograft with the addition of internal fixation. Postoperative radiographs were taken for the evaluation of bone healing. The functional results of the affected forearm were evaluated for motion loss of elbow or wrist and rotation loss of forearm.

      Results

      All nonunions healed without recurrent infection or loosening of internal fixation at the time of final follow-up. All the patients showed substantial functional improvement, with excellent results in 14 patients, satisfactory results in 13, and unsatisfactory results in 5.

      Conclusions

      The induced membrane technique is an effective solution for infected forearm nonunion.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Prasarn M.L.
        • Ouellette E.A.
        • Miller D.R.
        Infected nonunions of diaphyseal fractures of the forearm.
        Arch Orthop Trauma Surg. 2010; 130: 867-873
        • Ring D.
        • Allende C.
        • Jafarnia K.
        • Allende B.T.
        • Jupiter J.B.
        Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting.
        J Bone Joint Surg Am. 2004; 86: 2440-2445
        • Metsemakers W.J.
        • Emanuel N.
        • Cohen O.
        • et al.
        A doxycycline-loaded polymer-lipid encapsulation matrix coating for the prevention of implant-related osteomyelitis due to doxycycline-resistant methicillin-resistant Staphylococcus aureus.
        J Control Release. 2015; 209: 47-56
        • Pawar A.
        • Dikmen G.
        • Fragomen A.
        • Rozbruch S.R.
        Antibiotic-coated nail for fusion of infected charcot ankles.
        Foot Ankle Int. 2013; 34: 80-84
        • Bilgili F.
        • Balci H.I.
        • Karaytug K.
        • et al.
        Can normal fracture healing be achieved when the implant is retained on the basis of infection? An experimental animal model.
        Clin Orthop Relat Res. 2015; 473: 3190-3196
        • Kloen P.
        • Wiggers J.K.
        • Buijze G.A.
        Treatment of diaphyseal non-unions of the ulna and radius.
        Arch Orthop Trauma Surg. 2010; 130: 1439-1445
        • De Smet L.
        Treatment of non-union of forearm bones with a free vascularised corticoperiosteal flap from the medial femoral condyle.
        Acta Orthop Belg. 2009; 75: 611-615
        • dos Reis F.B.
        • Faloppa F.
        • Fernandes H.J.
        • Albertoni W.M.
        • Stahel P.F.
        Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating.
        Ann Surg Innov Res. 2009; 3: 5
        • Srinivasan R.C.
        • Hutson R.L.
        • Richard M.J.
        Forearm nonunion: characterization and management.
        J Hand Surg Am. 2020; 45: 1055-1064
        • Giannoudis P.V.
        • Harwood P.J.
        • Tosounidis T.
        • Kanakaris N.K.
        Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes.
        Injury. 2016; 47: S53-S61
        • Micev A.J.
        • Kalainov D.M.
        • Soneru A.P.
        Masquelet technique for treatment of segmental bone loss in the upper extremity.
        J Hand Surg Am. 2015; 40: 593-598
        • Walker M.
        • Sharareh B.
        • Mitchell S.A.
        Masquelet reconstruction for posttraumatic segmental bone defects in the forearm.
        J Hand Surg Am. 2019; 44: 342.e1-342.e8
        • Aho O.M.
        • Lehenkari P.
        • Ristiniemi J.
        • Lehtonen S.
        • Risteli J.
        • Leskelä H.V.
        The mechanism of action of induced membranes in bone repair.
        J Bone Joint Surg Am. 2013; 95: 597-604
        • Giannoudis P.V.
        • Faour O.
        • Goff T.
        • Kanakaris N.
        • Dimitriou R.
        Masquelet technique for the treatment of bone defects: tips-tricks and future directions.
        Injury. 2011; 42: 591-598
        • Masquelet A.C.
        • Begue T.
        The concept of induced membrane for reconstruction of long bone defects.
        Orthop Clin North Am. 2010; 41: 27-37
        • Zappaterra T.
        • Ghislandi X.
        • Adam A.
        • et al.
        Induced membrane technique for the reconstruction of bone defects in upper limb. A prospective single center study of nine cases.
        Chir Main. 2011; 30: 255-263
        • Jin Z.C.
        • Cai Q.B.
        • Zeng Z.K.
        • et al.
        Research progress on induced membrane technique for the treatment of segmental bone defect.
        Zhongguo Gu Shang. 2018; 31: 488-492
        • Ring D.
        • Jupiter J.B.
        • Sanders R.A.
        • et al.
        Complex nonunion of fractures of the femoral shaft treated by wave-plate osteosynthesis.
        J Bone Joint Surg Br. 1997; 79: 289-294
        • Sivakumar R.
        • Mohideen M.G.
        • Chidambaram M.
        • Vinoth T.
        • Singhi P.K.
        • Somashekar V.
        Management of large bone defects in diaphyseal fractures by induced membrane formation by Masquelet’s technique.
        J Orthop Case Rep. 2016; 6: 59-62
        • Gupta G.
        • Ahmad S.
        • Zahid Mohd
        • Khan A.H.
        • Sherwani M.K.
        • Khan A.Q.
        Management of traumatic tibial diaphyseal bone defect by “induced-membrane technique”.
        Indian J Orthop. 2016; 50: 290-296
        • Muhlhäusser J.
        • Winkler J.
        • Babst R.
        • Beeres F.J.P.
        Infected tibia defect fractures treated with the Masquelet technique.
        Medicine (Baltimore). 2017; 96e6948
        • Ring D.
        • Jupiter J.B.
        • Quintero J.
        • Sanders R.A.
        • Marti R.K.
        Atrophic ununited diaphyseal fractures of the humerus with a bony defect: treatment by wave-plate osteosynthesis.
        J Bone Joint Surg Br. 2000; 82: 867-871
        • Flamans B.
        • Pauchot J.
        • Petite H.
        • et al.
        Use of the induced membrane technique for the treatment of bone defects in the hand or wrist, in emergency.
        Chir Main. 2010; 29: 307-314
        • Luo T.D.
        • Nunez Jr., F.A.
        • Lomer A.A.
        • Nunez Sr., F.A.
        Management of recalcitrant osteomyelitis and segmental bone loss of the forearm with the Masquelet technique.
        J Hand Surg Eur. 2017; 42: 640-642
        • Schemitsch E.H.
        • Richards R.R.
        The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults.
        J Bone Joint Surg Am. 1992; 74: 1068-1078
        • Metsemakers W.J.
        • Morgenstern M.
        • McNally M.A.
        • et al.
        Fracture-related infection: a consensus on definition from an international expert group.
        Injury. 2018; 49: 505-510
        • Gustilo R.B.
        • Anderson J.T.
        Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.
        J Bone Joint Surg Am. 1976; 58: 453-458
        • Gustilo R.B.
        • Mendoza R.M.
        • Williams D.N.
        Problems in the management of type III (severe) open fractures: a new classification of type III open fractures.
        J Trauma. 1984; 24: 742-746
        • Kocaoglu M.
        • Eralp L.
        • Rashid H.U.
        • Sen C.
        • Bilsel K.
        Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail.
        J Bone Joint Surg Am. 2006; 88: 2137-2145
        • Parvizi J.
        • Zmistowski B.
        • Berbari E.F.
        • et al.
        New definition for periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society.
        Clin Orthop Relat Res. 2011; 469: 2992-2994
        • Morgenstern M.
        • Athanasou N.A.
        • Ferguson J.Y.
        • Metsemakers W.J.
        • Atkins B.L.
        • McNally M.A.
        The value of quantitative histology in the diagnosis of fracture-related infection.
        Bone Joint J. 2018; 100-B: 966-972
        • McCall T.A.
        • Brokaw D.S.
        • Jelen B.A.
        • et al.
        Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series.
        Orthop Clin North Am. 2010; 41: 63-73
        • Anderson L.D.
        • Sisk D.
        • Tooms R.E.
        • Park III, W.I.
        Compression-plate fixation in acute diaphyseal fractures of the radius and ulna.
        J Bone Joint Surg Am. 1975; 57: 287-297
        • Wilson F.C.
        • Dirschl D.R.
        • Bynum D.K.
        Fractures of the radius and ulna in adults: an analysis of factors affecting outcome.
        Iowa Orthop J. 1997; 17: 14-19
        • Haseeb M.
        • Muzafar K.
        • Ghani A.
        • Bhat K.A.
        • Butt M.F.
        A fresh look at radial shaft fracture fixation: The lateral approach to the radius.
        J Orthop Surg (Hong Kong). 2018; 262309499018780871
        • Faldini C.
        • Pagkrati S.
        • Nanni M.
        • Menachem S.
        • Giannini S.
        Aseptic forearm nonunions treated by plate and opposite fibular autograft strut.
        Clin Orthop Relat Res. 2009; 467: 2125-2134
        • Jewell E.
        • Merrell G.
        The use of a sliding bone graft in the upper extremity for long bone nonunions.
        J Hand Surg Am. 2015; 40: 1025-1027
        • Wood M.B.
        • Bishop A.T.
        Massive bone defects of the upper limb: reconstruction by vascularized bone transfer.
        Hand Clin. 2007; 23: 49-56
        • Safoury Y.
        Free vascularized fibula for the treatment of traumatic bone defects and nonunion of the forearm bones.
        J Hand Surg Br. 2005; 30: 67-72
        • Zhang Q.
        • Yin P.
        • Hao M.
        • et al.
        Bone transport for the treatment of infected forearm nonunion.
        Injury. 2014; 45: 1880-1884
        • Green S.A.
        Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects.
        Clin Orthop Relat Res. 1994; 301: 111-117
        • Masquelet A.C.
        • Fitoussi F.
        • Begue T.
        • Muller G.P.
        Reconstruction of the long bones by the induced membrane and spongy autograft.
        Ann Chir Plast Esthet. 2000; 45: 346-353
        • Akuji M.A.
        • Chambers D.J.
        Hydrogen peroxide: more harm than good?.
        Br J Anaesth. 2017; 118: 958-959
        • Goswami K.
        • Austin M.S.
        Intraoperative povidone-iodine irrigation for infection prevention.
        Arthroplast Today. 2019; 5: 306-308
        • Kombate N.K.
        • Walla A.
        • Ayouba G.
        • et al.
        Reconstruction of traumatic bone loss using the induced membrane technique: preliminary results about 11 cases.
        J Orthop. 2017; 14: 489-494
        • Woon C.Y.
        • Chong K.W.
        • Wong M.K.
        Induced membranes--a staged technique of bone-grafting for segmental bone loss: a report of two cases and a literature review.
        J Bone Joint Surg Am. 2010; 92: 196-201
        • Liu X.
        • Ding G.
        • Zhou D.
        • Xiang L.
        Antibiotic-loaded bone cement spacer usage combined with membrane induction in infected gap non-unions: a case series.
        Pak J Med Sci. 2018; 34: 1088-1093
        • Pelissier P.
        • Masquelet A.C.
        • Bareille R.
        • Pelissier S.M.
        • Amedee J.
        Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration.
        J Orthop Res. 2004; 22: 73-79
        • Pelissier P.
        • Martin D.
        • Baudet J.
        • Lepreux S.
        • Masquelet A.C.
        Behaviour of cancellous bone graft placed in induced membranes.
        Br J Plast Surg. 2002; 55: 596-598
        • Spinella-Jaegle S.
        • Roman-Roman S.
        • Faucheu C.
        • et al.
        Opposite effects of bone morphogenetic protein-2 and transforming growth factor-beta1 on osteoblast differentiation.
        Bone. 2001; 29: 323-330
        • Julka A.
        • Ozer K.
        Infected nonunion of the upper extremity.
        J Hand Surg Am. 2013; 38: 2244-2246
        • Olesen U.K.
        • Eckardt H.
        • Bosemark P.
        • Paulsen A.W.
        • Dahl B.
        • Hede A.
        The Masquelet technique of induced membrane for healing of bone defects. A review of 8 cases.
        Injury. 2015; 46: S44-S47
        • Ollivier M.
        • Gay A.M.
        • Cerlier A.
        • Lunebourg A.
        • Argenson J.N.
        • Parratte S.
        Can we achieve bone healing using the diamond concept without bone grafting for recalcitrant tibial nonunions?.
        Injury. 2015; 46: 1383-1388
        • Weiland A.J.
        • Phillips T.W.
        • Randolph M.A.
        Bone grafts: a radiologic, histologic, and biomechanical model comparing autografts, allografts, and free vascularized bone grafts.
        Plast Reconstr Surg. 1984; 74: 368-379
        • Allende C.
        • Mangupli M.
        • Bagliardelli J.
        • Diaz P.
        • Allende B.T.
        Infected nonunions of long bones of the upper extremity: staged reconstruction using polymethylmethacrylate and bone graft impregnated with antibiotics.
        Chir Organi Mov. 2009; 93: 137-142