Induced Membrane Technique for the Management of Segmental Femoral Defects: A Systematic Review and Meta‐Analysis of Individual Participant Data

Abstract

Several modifications of the induced membrane technique (IMT) have been reported, but there is no consensus regarding their results and prognosis. Moreover, most studies have focused on tibial defects; no meta‐analysis of the treatment of femoral defects using the IMT has been reported. This systematic review and meta‐analysis aimed to identify the potential risk factors of post‐procedural complications following the treatment of segmental femoral defects using the IMT. A comprehensive search was performed on the Cochrane Library, EBSCO, EMBASE, Ovid, PubMed, Scopus, and Web of Science databases, using the keywords “femur,” “Masquelet technique,” and “induced membrane technique.” Original articles composed in English, having accessible individual patient data, and reporting more than two cases of bony defect or nonunion of femur or more than five cases of any body part were included. Post‐procedural bone graft infections, final union status, and union time after second‐stage operation were analyzed. Fourteen reports, including 90 patients, were used in this study. External fixation in second‐stage surgery had an odds ratio of 9.267 for post‐procedural bone graft infection (p = 0.047). The odds ratio of post‐procedural bone graft infection and age >65 years for final non‐union status was 51.05 (p = 0.003) and 9.18 (p = 0.042). Shorter union time was related to impregnated antibiotics in the spacer (p = 0.005), transplanting all‐autologous grafts (p = 0.042), and the application of intramedullary nails as the second‐stage fixation method (p = 0.050). The IMT appears to be reasonable and reproducible for femoral segmental bone defects. Several preoperative and surgical factors may affect post‐procedural complications and union time.

The induced membrane technique for the management of infected segmental bone defects

“…3,6,22,47 A recent meta-analysis of the management of femoral bone defects with the IMT showed that a shorter union time was related to the use of an all-autologous graft. 32 To prevent excessive resorption during the incorporation of grafted bone, the ratio of bone graft expanders must be controlled. The negative effects of smoking on bone healing time and union have been demonstrated in both clinical and basic studies.…”

“…In the last decade, the IMT has been widely used in clinical practice because of its marked effects. 11,31,32 However, mixed results have been reported in the management of infected segmental bone defects, 7 with success rates ranging from 45% 8 to 97%. 9 To our knowledge, predictive factors associated with unfavourable outcomes have yet to be confirmed directly in large clinical studies.…”

Treatment of infected bone defects with the induced membrane technique

“… 81 A recent systematic review suggested that old age (age ≥ 65 years) might be a risk factor for final nonunion status for managing femoral bone defects with the induced membrane technique. 16 Therefore, for elderly patients with other risk factors for bone healing, second-stage reconstruction should be performed cautiously, and even second-stage surgery should be delayed indefinitely. Cierny 82 and Shen et al 13 reported a method using permanent spacers, composed of various antibiotic-impregnated bone cement reinforced with a nail, pin, or plate, to treat infected bone defects successfully, which might be effective, but long-term follow-up observations are needed.…”

“…8,9 For example, antibiotics were added to the bone cement in the first stage, 10,11 internal fixation was established as a stabilization method, [12][13][14] osteoinductive factors were included, and allograft and osteoconductive scaffold for bone graft expender were added in the second stage. 6,10,11 Although some systematic reviews and meta-analyses have discussed these changes, they included bone defects caused by various factors, 6,10,11,15,16 or other treatment methods. 17 Therefore, we conducted a systematic review to explore the factors affecting the patient outcomes of infected bone defect treated with the induced membrane technique.…”

Incidence and Risk Factors for Extremity Osteoradionecrosis after Limb-Sparing Surgery and Adjuvant Radiotherapy

“…Adequate debridement to remove all of the devitalized soft tissue and bone is essential for the initial treatment. We would collaborate with an orthopedic surgeon to either achieve rigid bone fixation or apply the induced membrane technique if a segmental bony defect is present after sequestrectomy [ 47 ]. Systemic control with intravenous or oral antibiotics was always required for the secondary infection and was also supplemented with antibiotic-containing beads locally.…”