Bone reconstruction with modified Masquelet technique in open distal femoral fractures: a case series

Abstract

Background: Large bone defects require complex treatment, multidisciplinary resources, and expert input, with surgical procedures ranging from reconstruction and salvage to amputation. The aim of this study was to provide the results of a case series of open comminuted intra-articular distal femoral fractures with significant bone loss that were managed by early fixation using anatomical plates and a modified Masquelet technique with the addition of surgical propylene mesh.

Methods: This retrospective study included all patients referred to our institution with OTA/AO C3 distal femur open fractures and meta-diaphyseal large bone loss between April 2019 and February 2021. We treated the fractures with irrigation and debridement, acute primary screw and plate fixation in the second look operation, and Masquelet method using shell-shaped antibiotic beads supplemented by propylene surgical mesh to keep the cements in place. The second step of the procedure was conducted six to eight weeks later with bone grafting and mesh augmentation to contain bone grafts. Surprisingly, hard callus formation was observed in all patients at the time of the second stage of Masquelet procedure.

Results: All five patients' articular and meta-diaphyseal fractures with bone loss healed without major complications. The average union time was 159 days. The mean knee range of motion was 5-95 degrees. The average Lower Extremity Functional Score (LEFS) was 49 out of 80.

Conclusions: Combination of early plate fixation and the modified Masquelet technique with polypropylene mesh is an effective method for managing large bone defects in open intra-articular distal femoral fractures with bone loss, resulting in shorter union time possibly associated with the callus formation process. This technique may also be applicable to the management of other similar fractures specially in low-income and developing areas.

Keywords: Bone defect; Bone loss; Induced membrane; Open femoral fracture.

Fig. 1

Filling the segmental defect with shell-shaped, antibiotic-impregnated cement beads

Fig. 2

Standard polypropylene surgical mesh

Fig. 3

Suturing the mesh to the plate and to itself and layered closure of the wound

Fig. 4

Hard callus formation in X-ray. (A) Patient One, (B) Patient Two

Fig. 5

Propylene mesh surrounded by callus formation

Fig. 6

Granulation tissue formation from previous mesh site sections, Hematoxylin & Eosin, x100 (A) and x400 (B)

Fig. 7

Removing the antibiotic beads

Fig. 8

Pre-op X-rays. (A) Patient One (B) Patient Two

Fig. 9

Follow-up X-ray after 3 months of bone grafting in a case with open C3 distal femur fracture. (A) Patient One (B) Patient Two