Clinical and functional outcomes of masquelet technique for treating Fracture-related Infections(FRIs) in shoulder girdle

Abstract

Structural and functional integrity pose a challenge for the treatment of fracture-related infections (FRI) in the shoulder girdle. The purpose of this study was to assess the clinical and functional outcomes of patients treated with the Masquelet technique. From January 2012 to January 2023, sixty-two consecutive adult patients with FRI in the shoulder girdle (8 in clavicle and 54 in humerus) were treated using this technique. This involved the use of antibiotic bone cement to fill the dead space after debridement, followed by staged bone grafting. Patients' outcomes, in terms of infection resolution, bone union, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score, were retrospectively analyzed. The follow-up time was at least 2 years. The mean age was 45.52±14.01 years. The initial fracture was open in 16 patients (25.8%) and closed in 46 patients (74.2%), Staphylococcus aureus (21.0%) was the most common pathogen. Thirty-six patients with large bone defects had additional locking plates for internal fixation. All patients achieved bone consolidation after a median follow-up of 24 months (range: 24-72 months) after the second stage bone graft. Clinical bone healing occurred at 4 months in 56.5%, at 6 months in 29.0%, and at 9 months in 14.5%. Seven patients required additional revision surgery. Three of these patients underwent repeated debridement before grafting due to incomplete infection control, while four had recurrence after the second-stage bone graft and required repeat surgery. The average DASH scores showed a significant decrease at the final follow-up, from a mean of 47.37 before surgery to a mean of 13.31. Following univariate analysis, patient age, post-debridement internal fixation, and bone graft type were not associated with the need for additional revision. However, patients aged ≥ 60 years (p = 0.004) and those with prolonged infection duration (p=0.002) were more likely to experience poor functional outcomes. The Masquelet technique, though requiring a staged approach, achieved reliable infection control and bony union in shoulder girdle FRIs, with favorable functional outcomes. This staged technique provided advantages through the use of antibiotic-loaded cement spacers, enabling local antibiotic treatment, dead space management, and post-debridement internal fixation.

Keywords: Fracture-related infection; Function; Masquelet technique; Shoulder girdle.

Fig. 1

Intraoperative view from a 24-year-old male with FRI in clavicle, treated with Masquelet Technique. (a)Multiple sinus tract in the wound in midshaft clavicle. (b) Plate fixation after radical debridement. (c) The antibiotic-coated cement spacer filled the bone defect and coated the plate. (d) Complete infection control and soft-tissue healing before bone graft in the second stage. (e) The cement was removed and protecting induced membrane in second stage, (f) then the defect was restabilized and with bone graft.

Fig. 2

Imaging and functional results of a 24-year-old male with FRI in clavicle, treated with Masquelet Technique. (a)X-ray of a patient with FRI in midshaft clavicle. (b) Post-debridement X-ray with an antibiotic cement spacer and a plate for internal fixation. (c) X-ray of bone healing state 2 years after second stage bone grafting. (d) Functional result at the two-year follow-up showing good infection control and wound healing, (e) full stretch and full elevation of shoulder joint (f).

Fig. 3

Staged surgical treatment of a 35-year-old male with FRI in humerus by Masquelet Technique. (a) Preoperative X-ray showing nonunion of midshaft humerus and an external fixture treatment. (b) Intraoperative view showing a wound exudation and an external fixator. (c-e) Remove external fixator, radical debridement, an cement spacer filled the bone defect and internal fixation with a plate. (f-g) Imaging and soft-tissue evaluation before bone graft in the second stage. (h-i) redebridement, replacing implant and bone grafting in second stage surgery.

Fig. 4

Imaging and functional results of a 35-year-old male with FRI in humerus, treated with Masquelet Technique. Radiograph follow-up with 2 month (a) and 4 month (b) after second stage bone graft. The long-term follow-up at 9 month (c), 12 month (d), 24 month (e) and 36 month (f), showing an complete bone healing achieved. (g-h) Functional result at the two-year follow-up showing good stretch and elevation movement.