Possibility of one-stage surgery to reconstruct bone defects using the modified Masquelet technique with degradable calcium sulfate as a cement spacer: A case report and hypothesis

Abstract

Abstract. In addition to autologous bone graft, vascularized fibular autograft and Ilizarov bone transfer, the Masquelet technique is another effective method to reconstruct bone defects. This technique was initially proposed in 1986 and consists of two stages. At the first stage, radical debridement is required and subsequently, a polymethylmethacrylate (PMMA) cement spacer is implanted at the site of the bone defects. At the second stage, when the PMMA-induced membrane is formed 6-8 weeks later, the cement spacer is carefully removed in order to not disturb the induced membrane and the bone graft is performed to fill the bone defects. Although this technique has resulted in satisfactory outcomes in the reconstruction of bone defects, the PMMA spacer used to induce membrane is not degradable and requires surgical removal. In recent years, calcium sulfate has been used as a localized antibiotic delivery vehicle and bone substitute due to its superiorities over PMMA, particularly its completely degradable nature. The present study identified that calcium sulfate can also induce the formation of a membrane. In addition, we hypothesized that the degradability of calcium sulfate may allow one-stage reconstruction of bone defects. The current study presents a clinical case report and review of the literature. IntroductionThe aim of bone defect reconstruction is to regenerate bone loss and restore limb function (1). Several approaches can be adopted in the clinic, including autologous bone graft, vascularized fibular autograft and the Ilizarov bone transfer technique. Autologous bone graft is not recommended for reconstruction of massive bone defects due to its increased risk of resorption (2). Vascularized fibular autograft and the Ilizarov bone transfer technique are the most frequently used methods for reconstruction of extensive bone defects (3-5).The Masquelet technique is another effective way to repair extensive bone defects. This two-staged method for bone reconstruction was first described by Masquelet et al in 1986 (6). The first-stage surgery includes radical debridement of bone and soft tissues, followed by implantation of a polymethylmethacrylate (PMMA) cement spacer at the site of the bone defects. The cement spacer is expected to obviate invasion of fibrous tissue at the recipient site (mechanical role) and induce the surrounding membrane (biological role) (7). After a duration of 6 to 8 weeks, a PMMA-induced pseudosynovial membrane formed. At the second-stage surgery, the cement spacer is removed carefully in order to maintain the already formed membrane and cause minimal disturbance. Following this, the defect is filled with morcellised cancellous autologous bone graft. Masquelet et al (6) reported that this method could repair a bone defect of 25 cm in length.Since the first study, the Masquelet technique has been widely used to resolve massive bone defects caused by different diseases and achieved clinical efficacy (8-12). However, efficacy in the cases managed by the Masquelet technique does not me...

Calcium sulfate induced versus PMMA-induced membrane in a critical-sized femoral defect in a rat model

“…It has also been widely used in clinic as a local antibiotic carrier for the treatment of chronic osteomyelitis, because it is totally absorbed over a period of several weeks, releasing the entire antibiotic load 19 . We found that it also induced formation of membrane-like structure in clinical cases 20 , but the histological and biochemical characteristics of the CS-induced membrane were unclarified. There has been no research addressing these problems as well as the differences between the PMMA-induced versus the CS-induced membranes in repair of large segmental bone defects.…”

Bone grafts and biomaterials substitutes for bone defect repair: A review

“…More recently, Nan Jing et al. [86] modified the traditional Masquelet technique, which has been widely used in treating massive bone defects, by using calcium sulfate to replace the PMMA as cement spacer, so as to make this technique a one-step surgery. In this case report regarding the reconstruction of an open fracture of the calcaneus at right foot, they found the formation of the induced membrane with the implantation of calcium sulfate by X-ray image and a computed tomography scan.…”

“…In this case report regarding the reconstruction of an open fracture of the calcaneus at right foot, they found the formation of the induced membrane with the implantation of calcium sulfate by X-ray image and a computed tomography scan. But this trial was then stopped by the patient and the calcium sulfate was finally replaced by autologous iliac crest bone grafts, and further characterization on the induced membrane and bone regeneration became impossible [86] .…”

Influence of Chromium-Cobalt-Molybdenum Alloy (ASTM F75) on Bone Ingrowth in an Experimental Animal Model

“…After approximately four or eight weeks, a bone substitute, generally an autologous bone graft that includes all of the possible limitations mentioned above, is placed. Since the first study, the Masquelet technique has been widely used and modified with the development of new technologies to solve massive bone defects, while maintaining its clinical efficacy [ 10 , 11 , 12 ]. In a similar way, in the last few decades, the rigid, osteoconductive, and non-resorbable barrier membranes are used as part of regenerative treatments, and bone augmentation therapies have been thoroughly researched [ 13 ] as additional methods to improve osteoinduction and cell differentiation mechanisms [ 14 , 15 , 16 , 17 , 18 , 19 ].…”