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will be left alone, and the recon-struction will be a challenge in-side scar tissue.Metaphyseal bone defects are stillgood indications for the tech-nique. At the level of the defect,vascularisation is often in a badcondition secondary to trauma.Due to the presence of scar tissuewith poor vascular supply, theinduced membrane technique isa good choice as it allows build-ing of a better quality bone graftbed. As previously discussed, sta-

area is also a good option for theinduced membrane technique asinternal fixation can be as stableas in the diaphysis location.When stabilisation was possible,we have done cases on inducedmembrane in the metaphysealarea. In the epiphysis, the op-portunity for the induced mem-brane must be balanced with thefunction we can expect for thenearby joint after reconstruction. As far as segmental large bonedefects are concerned, the issueis to find other options for suchcases. It is not so easy. For limit-ed defects, which length is belowthe diameter of the mid-diaph-ysis, any autologous bone graftwill be the treatment of choice.When the length is over the di-ameter, any classical method oftreatment gives a high percentageof failure. The main advantageof the induced membrane tech-nique is to fill up the defect at thetime of the resection for dead tis-sues. This piece of cement is wellfixed proximally and distally, in-side the medullary canal of bothextremities. The induced mem-brane technique may be usedwhatever is the length of the de-fect. In addition, if there is a fail-ure as bone graft osteolysis, allother options are still available.So, it is not a dead-end thera-peutic option. This technique isof value when the surgeon has toconsider a Damage Control man-agement for difficult cases (Fig.2). In such cases, in acute treat-ment phase, the technique mustbe compared to immediate short-ening and secondary lengthen-ing. Immediate shortening maybe used in defects of and less, asthe vascular supply distally willnot tolerate more extensive short-ening. In other cases, the defect

Large bone defects are a chal-lenging situation for surgeons,either in acute management, ei-ther in case of a nonunion or aseptic nonunion. Different treat-ment proposals have been madesince a long time using autolo-gous cancellous bone graft, open-air cancellous Papineau grafting,free vascularized bone transfer,bone transport or al lograft(1,2,3). Since 2000, the inducedmembrane technique, so-calledthe Masquelet technique, hasbeen described for treatment ofsuch very difficult cases that wecan express as treatment of crit-ical sized bone defects (4,5). Dif-ferent types of cases have beentreated since that, using eitherthe original concept or lightmodifications. Additional tipsand tricks were developed allover our practice so that actualinduced membrane techniquehas a huge amount of possibili-ties that surgeons must be awareof when using it.In the following, we’ll try to giveas much details as possible for apositive result when using theinduced membrane technique.Clinical based algorithm will beemphasized. Remaining un-solved items will be discussed.

What are bone defects suita-ble for the induced membranetechnique

Segmental bone defects

The main indication for the in-duced membrane technique is asegmental bone defect locatedon the mid-diaphysis, withlength over the diameter of thebone at this level. All long bonesmay be involved, and we haveused the technique for tibia, fe-mur, humerus and radius,ranked in a decreasing manner(Fig. 1). The median third of along bone is the prototype forthe technique, as mechanicalstrains are high, as well as corti-calisation for a solid construct.Such a defect needs very stableosteosynthesis that is easy to getas proximal and distal fixation isof sufficient length. Metaphyseal

tween the bone graft and the re-cipient normal bone. Insertionof the cement creates a completesurrounding membrane witchmay interfere with fusion afterthe bone graft insertion. So,when removing the cement, andbefore graft insertion, surgeonmust eliminate the membrane lo-cated inside the recipient bone,leaving only the one located out-side the bone to get a completehealing process with restorationof bone geometry. In addition,maintaining the membrane out-side the bone will give stimula-tion of vascular supply to thegraft.

Which bones are suitable forthe induced membrane technique?

We have used the induced mem-brane technique in all longbones, either in the lower limbfor tibia and femur, or the upperlimb for humerus, radius and ul-na. We didn’t get experience withthe fibula, as reconstruction ofthis bone may be controversialregarding the morbidity of allprocedures. We have used theinduced membrane in non-haversian bones such as huge de-fects of the clavicle, with good re-sults as well. The large amount ofbones treated since the begin-ning of the technique in the ear-ly 90’s gave to us possibilities tofix and highlight some tips andtricks to get the best results ever.As the “gold standard” techniqueis for tibia reconstruction, wefound the optimal interval be-tween spacer insertion and re-moval for bone graft refilling wasof 6 weeks. In other locations,this interval is not exactly thesame, and nowadays we try tomaintain the cement spacer 2-3months for the humerus, and 5-6 months for the femur. Resultsobtained in these bones whenwe have left the cement spacerfor a shorter period of time werenot as good, and the membranequality, in terms of vascularity,thickness and mechanical resist-ance as not as good as in the tib-ia. In the aetiology of such re-sults, we can involve the vascu-larisation of the thigh or the arm,as they have only one major ves-sel to assume complete vascu-larisation of the segment, insteadof three for the leg. We can con-clude that revascularisation ofthe surrounding tissues of thespacer is done in the leg and fore-arm from different areas, and canbe rather quick, instead of oneside only in the femur and arm,resulting in a more difficult com-plete revascularisation of the sur-rounding tissues.

How to do it for an optimalresult?

The induced membrane tech-nique is a challenging one, notonly for the concept, but also forthe technical aspects. Both pro-cedures need to be well done tooffer the optimal results after thebone graft.When doing the first time pro-cedure, all scar and dead tissuesmust be removed. This resectionphase includes bone so that atthe end of the resection, both ex-tremities are well vascularizedwith good blood flow seen fromthe bone. But the resection in-cludes also the soft tissue sur-rounding the defect. The bestway to do this with confidence isto ignore the problem of the re-construction, to avoid a limitedresection, which will lead to afailure of the technique. We re-move the tourniquet at the endof the resection phase, to checkthe correct blood supply of allremaining tissues around the de-fect. At that time, the defect isfilled up with the cement in aputty phase, so it can be moldedinside the defect and restore thenormal length and width of thebone (Fig. 3). In addition, thecement must be introduced in-side the medullary canal of bothextremities, within 1 cm oflength. Doing this, the surgeonmust also cover the external partof the extremities, so that somekind of a tulip flower aspect willbe the design of the cement atjunction with the proximal anddistal bone. After the cement willbe solid, there will be some kindof stability of the cement spacer.It will help to build up a good in-duced membrane.When doing the second timeprocedure, the surgical approachmust be done with a knife toopen longitudinally the mem-brane. At both ends, decortica-tion of bone must be done, incontinuity with the membrane. Itmust be done like an open bookdown to the entire diameter ofthe bone. In our practice, we doall that surgery with chisels sothat some bone chips can be el-evated with the membrane.Breakage of the cement spacer isdone with the chisels, withoutmodifying the stability of the en-tire segment, so that no injuryand no rupture to the membranewill be done. After, fragments in-cluded in the medullary canalare removed, and resection of the

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The induced membrane technique for treatment of large segmentalor cavitary bone defects: How to maximize the successTh. Bégué, J. Ch AureganDepartment of Orthopaedics and Trauma Surgery, Antoine Béclère Hospital, University Paris-Sud

DOI 10.1007/s10261-013-0046-1

Th. Bégué

ABSTRACT

Large bone defects are a challenging situation for surgeons, either in acutemanagement, either in case of a nonunion or a septic nonunion. Differenttreatment proposals have been made since a long time using autologouscancellous bone graft, open-air cancellous Papineau grafting, free vascu-larized bone transfer, bone transport or allograft (1,2,3). Since 2000, theinduced membrane technique, so-called the Masquelet technique, has beendescribed for treatment of such very difficult cases that we can express astreatment of critical sized bone defects (4,5). In the following, we'll try togive as much details as possible for a positive result when using the inducedmembrane technique. Clinical based algorithm will be emphasized.

Fig. 1. Segmental bone defect located on themid-diaphysis

Fig. 2. Damage control management

bility of bone fragments is a key-point of the technique. In meta-physeal areas, it may be difficultto get a stable device with goodanchorage in the fragments. Inepiphyseal locations, the inducedmembrane technique may beused. However, the future func-tion of the close joint will be themost important factor. If fusionis selected, prior insertion of a ce-ment spacer may be a good op-tion before bone graft insertion.

Cavitary bone defects

As positive results were obtainedwith the induced membranetechnique in segmental bone de-fects, we have used it in cavitaryones. Are included in such defi-nition any types of defects wherebone continuity is preserved, atleast with 1/3 of cortical bonecontact. It can be observed intraumatic or non-traumatic de-fects such as benign tumor re-section. The main considerationabout modification of the tech-nique in such locations is themanagement of the junction be-

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membrane in the medullarycanal done as well. Then, thebone graft is inserted in the de-fect and in the membrane bed,filling completely the defect with-out excessive impaction. Nodrainage is suitable.

What type of Bone graft?

Autologous bone graft is far bet-ter than any other product avail-able for the induced membranetechnique. Using that type ofgraft gave us quick reconstruc-tion aspect with bone continuity,good recorticalisation of the graft,and the quicker full weight-bear-ing delay. However, the volumeof autologous bone graft avail-able is limited and extensivebone defect cannot be treatedwith such options.Allografts have been used insome cases. All were mixed withautologous graft and morcelizedcancellous allograft. Some con-cerns may involve the percentageof each part of graft in the mix-ture. We never did more than60% of autologous and 40% ofallograft. With such a mixture,results were quite similar to theones done with autologous bonegraft alone.We have tried bone substitutes,such as Calcium Phosphate gran-

ules. Products are so different re-garding macroporosity and mi-croporosity that we didn’t get anypositive conclusion using suchproducts.Nowadays, we are using theR.I.A. (Reaming Irrigation Aspi-ration) system (6) to enhance thevolume of the autologous bonegraft available (Fig. 4). Graftquality and strength is not equalto iliac bone graft, but the finalresults of our cases using the RIAare quite similar to the “goldstandard” method (Fig. 5).Additional BMP to stimulate thereconstruction phase have been

tested in our experience. Resultswere not always positive, withsome cases of osteolysis whenusing the BMP within 6 weeks af-ter cement insertion. Pelissierand colleagues (7) have made anexperimental study about the in-duced membrane technique, andtheir results emphasized the roleof natural bone growth factorsproduced inside the membrane.We think that, probably, somebad results were due to adverseeffects between natural bonegrowth factors produced by themembrane and chemical pro-duced ones, inserted in addition.So, now, we use BMP when thetime for the secondary procedureis far away of the spike produc-tion of natural bone growth fac-tor.

Conclusion

The induced membrane tech-nique is a good answer for re-construction of large bone de-fects, doing tissue engineeringwith a global “diamond concept”management, such as stability ofthe non-union. Additional mes-enchymal stem cells are neededfor complete bone reconstruc-tion. Probably, the induced mem-brane technique is an answer fordifferent problems the surgeonhas to deal with, and must becompared to the Bone transportor free fibula transfer for recon-struction of large bone defects.

References

1. Watson JT, Anders M, Moed BR.(1995) Management strategiesfor bone loss in tibial shaft frac-tures. Clin Orthop Relat Res315:138-52

2. Meinig R. (2011) Managementof Traumatic Bone Defects. InPape H-C, Sanders R, Borrelli JJ,editors. The Poly-TraumatizedPatient with Fractures, Sprin-ger Berlin Heidelberg p. 295-303

3. Marino JT, Ziran BH (2010) Useof solid and cancellous autolo-gous bone graft for fractures andnonunions. Orthop Clin NorthAm 41:15-26

4. Masquelet A, Fitoussi F, BegueT, Muller GP (2000) Recon-struction of the long bones bythe induced membrane andspongy autograft. Ann ChirPlast Esthet 45:346-53

5. Masquelet AC, Begue T (2010)The concept of induced mem-brane for reconstruction of longbone defects. Orthop ClinNorth Am 41:27-37

6. Sands S, Siska P, Tarkin I.(2011) Reconstructive Strate-gies for Skeletal Complicationsin the Polytrauma Patient. In:Pape H-C, Sanders R, Borrelli JJ,editors. The Poly-TraumatizedPatient with Fractures SpringerBerlin Heidelberg p. 333-44

7. Pelissier P, Masquelet AC, Ba-reille R et al (2004) Inducedmembranes secrete growth fac-tors including vascular andosteoinductive factors and couldstimulate bone regeneration. JOrthop Res 22:73-9

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Fig. 3. Masquelet technique. First time procedure. Resection of dead bone and soft tissue and fill upthe defect with cement

Fig. 5. X-ray control are quite similar to the gold standard method ( autologous bone graft from iliac crest)

Fig. 4. Masquelet technique. Second time procedure. The defect fill up with autologous bone graftusing R.I.A