Induced membrane technique for large bone defects

Abstract

Aims:The aim of this study was to evaluate the efficacy of induced membrane technique (IMT), and to analyze the relationships between patient factors and surgical parameters as well as their impacts on achieving bone union and complication rates.Materials and methods: A comprehensive, computerized search of PubMed, Embase, and The Cochrane Library was conducted, and articles published from January 1, 1978 to February 1, 2021 were included. Clinical trials matching the following inclusion criteria were included:1. published as a case series, case-controlled studies, or cohort study; 2. IMT was performed for more than 10 cases within the study.Univariate and multivariate logistic regression were performed with random intercepts to determine the association of specific predictor variables with nonunion rate, postoperative infection, the need for additional procedures, and time to union.Results: Seventy eight trials were included in the study with a total of 3840 patients managed with IMT. Mean age was 38.6 (0.8-88) years, mean size of bone defects was 6.4 (0-25) cm primarily distributed in the tibia (n = 1814, 60.9%), and overall union rate was 87.6%. Multivariate analysis showed the odds of nonunion were significantly increased in patients with an interval between two stages from 8 to 12 weeks and ≥12 weeks. Patients with preoperative infection and addition of antibiotic to bone cement during IMT had significantly decreased odds of longer union time, but preoperative infection caused increased odds of additional surgery. External fixation throughout 2 stages had significantly increased odds of postoperative infection and additional surgery.Conclusions: We recommend that the timing of the second stage should be delayed until 6 to 8 weeks after the first stage. Bone cement with antibiotics can control the infection rate and shorten the healing time. Furthermore, there is no need to avoid using internal fixation due to possible concerns about causing postoperative infection.Abbreviations: BMP-2 = bone morphogenetic protein-2, CI = confidence interval, ICBG = iliac crest bone graft, IMT = induced membrane technique, NOS = Newcastle-Ottawa Scale, PMMA = polymethylmethacrylate, RIA = irrigator aspirator.

Current Management of Acute and Posttraumatic Critical Bone Defects

“…77 Younger patients, femoral defects, and bone cement in the antibiotics were protective factors against nonunions and the need for additional surgical procedures. 77 Other studies have reported initial procedure healing rates of 86% in adults and 60% in pediatric patients. Those rates improve to 90% in patients who undergo additional grafting or additional surgical procedures.…”

“…74,75,80,81 A recent systematic review reported a union rate of 87% overall, almost 95% in infectious cases and 85% in noninfectious cases. 77 Antibiotic PMMA during the first stage, preoperative infection, and intervals less than 8–12 weeks between the first and second stages were associated with higher rates of union. 77 Younger patients, femoral defects, and bone cement in the antibiotics were protective factors against nonunions and the need for additional surgical procedures.…”

“…6A, B). 67,70,77 Definitive soft tissue closure with free tissue transfer, local rotational flaps should be performed during this first stage of care if necessary. The presence of a stable, subtle, and mobile soft tissue envelope is critical to bone grafting during stage 2 of this surgical technique.…”

“…78 Infection (21%-60%) is the most common reported complication, and it is most commonly due to insufficient first-stage debridement. 77,81,83 Nonunion rates have been reported as high as 11.2%, and amputation rates have been reported in up to 4% of patients. 77 Masquelet's publication from the series of patients in the French Society of Orthopaedic Surgery and Traumatology evaluated alignment in their patients and reported 17% malunion rate with 16% of their patients requiring corrective procedures for deformity.…”

“…77,81,83 Nonunion rates have been reported as high as 11.2%, and amputation rates have been reported in up to 4% of patients. 77 Masquelet's publication from the series of patients in the French Society of Orthopaedic Surgery and Traumatology evaluated alignment in their patients and reported 17% malunion rate with 16% of their patients requiring corrective procedures for deformity. 75 In that series, the failures occurred in the open tibias and 2 patients had associated vascular injuries.…”