Infected tibia defect fractures treated with the Masquelet technique

Abstract

The treatment after open and infected fractures with extensive soft tissue damage and bone deficit remains a challenging clinical problem. The technique described by Masquelet, using a temporary cement spacer to induce a membrane combined with reconstructive soft tissue coverage, is a possible solution. This study describes the work-up, operative procedure, complications, and the outcome of a homogenous group of patients with an open and infected tibia fracture and segmental bone loss treated with the Masquelet technique (MT).This retrospective study evaluates patients having sustained an open tibia fracture treated with the MT between 2008 and 2013 with a follow up of at least 1 year. The defect was either primary, caused by a high-grade open fracture or secondary due to a non-union after an open fracture. Prerequisite conditions prior to the procedure of the Masquelet were a defect zone with eradicated infection, an intact soft tissue cover and stability provided by an external fixation.Volume of the defect, time until the implantation of the spacer, time of the spacer in situ and the time to clinical and radiological union were evaluated. Patient records were screened for reoperations and complications. The functional clinical outcome was measured.Eight patients were treated with a follow up over 1 year. The spacer was implanted after a median of 11 (2-70) weeks after the accident. The predefined conditions for the Masquelet phase were reached after a median of 12 (7-34) operations.Seven patients required reconstructive soft tissue coverage. The volume of the defect had a median of 111 (53.9-621.6) cm, the spacer was in situ for a median of 12 (7-26) weeks. Radiological healing was achieved in 7 cases after a median time of 52 (26-93) weeks.Full weight bearing was achieved after a median time of 16 (11-24) weeks. Four patients needed a reoperation. The lower limb functional index was a median of 60% (32-92%).Seven out of 8 patients treated in this group of severe open and infected tibia fractures did both clinically and radiologically heal. Due to the massive destruction of the soft tissue, patients needed several reoperations with soft tissue debridements and reconstruction before the spacer and the bone graft could be implanted.

Figure 1

A. Male, 53 years; tibia fracture after a bike accident (AO 42 C3, Gustillo-Anderson 3b). B. Temporary treatment with an external fixation. C. Stage I of the Masquelet phase after 12 days. The spacer was exchanged after 16 weeks for a spongiosa plastic. Meanwhile 12 operations were needed to obtain adequate soft tissue coverage with a latissimus dorsi flap. D. Radiological healing after 56 weeks, full weight bearing 11 weeks after the spongiosa plastic. AO = Arbeitsgemeinschaft für Osteosynthesen.

Figure 2

A. Male, 53 years, distal intra-articular tibia fracture (AO 43-C2) after a crush accident, Gustillo Anderson 3. B. Initial treatment with an external fixation. C. Fixation with a distal tibia plate and a first Palacos spacer 5 weeks after trauma. Musculo-catenous flap coverage, initially with a gracilis flap, after infection and necrosis a latissimus dorsi flap. D. Spongiosa plastic after removal of the Palacos Spacer 31 weeks after the accident. E. Spongiosa plastic in situ. F. Radiological union 93 weeks after the initial trauma. Additional stability has been given by a plate after distal migration of the nail. AO = Arbeitsgemeinschaft für Osteosynthesen.