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The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A case report
Accepted Manuscript Title: The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A Case Report Authors: Silvio Demitri, Giovanni Vicenti, Massimiliano Carrozzo, Davide Bizzoca, Dania De Franceschi, Biagio Moretti PII: DOI: Reference:
S0020-1383(18)30707-1 https://doi.org/10.1016/j.injury.2018.11.039 JINJ 7952
To appear in:
Injury, Int. J. Care Injured
Received date: Revised date: Accepted date:
11 August 2018 19 November 2018 23 November 2018
Please cite this article as: Demitri S, Vicenti G, Carrozzo M, Bizzoca D, De Franceschi D, Moretti B, The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A Case Report, Injury (2018), https://doi.org/10.1016/j.injury.2018.11.039 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A Case Report Silvio Demitri1, Giovanni Vicenti2, Massimiliano Carrozzo2, Davide Bizzoca2, Dania De Franceschi1, Biagio Moretti2 Clinic of Orthopaedics, Academic Hospital of Udine, Italy. School of Medicine, University of Bari “Aldo Moro”- AOU Consorziale “Policlinico”, Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic and Unit, Bari, Italy. Corresponding author: Giovanni Vicenti, M.D: Department of Basic Medical Sciences, Neuroscience and Sense Organs. Orthopaedic Clinic. School of Medicine, University of Bari “Aldo Moro”. AOU Consorziale Policlinico. Piazza Giulio Cesare 11, 70100 Bari, Italy. Tel: +39 0805593402 E-mail: [email protected] 1
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2
Abstract:
U
The treatment of open distal tibia fractures remains challenging, particularly when the fracture
N
involves severe soft tissue damage and segmental bone loss.
We present the case of a 33-year-old woman who sustained an open distal tibia fracture type 43-
A
A3.3, with segmental bone loss, and a closed bifocal fibular fracture.
M
The fractures were initially fixed with a temporary external fixator. The open distal tibial fracture underwent an endomedullary nailing on day six post-trauma, while the segmental bone loss was
ED
refilled with a temporary cement spacer, in order to create a biologic chamber, according to the technique by Masquelet et al.
PT
At three months post-trauma, the temporary cement spacer was removed and the bone loss was filled with an autologous bone graft obtained with the Reaming Irrigation Aspiration (RIA) system. The fracture successfully healed at 13 months post-trauma.
CC E
Masquelet technique, in association with the RIA system, represents a valid strategy in the treatment of non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss.
A
Key-words: Masquelet technique; case report; Reaming Irrigation Aspiration (RIA); open distal tibia fracture; endomedullary nail.
1
Introduction: Open distal tibia fractures, including extraarticular fractures of the metaphysis and intra-articular plafond fractures, are a quite common injury with a reported annual incidence of about 3.4 per 100,000 [1-2]. This kind of fracture commonly results from high-energy trauma, i.e. falls from heights, pedestrian or motor vehicle accidents [2-3]. Because of the subcutaneous location of the tibia, segmental bone defects could be observed in 68-
IP T
79% of distal tibia fractures [4-6]. The treatment of such a kind of fractures is a big challenge, since it may cause a long-term morbidity in terms of soft tissue necrosis, surgical site infection, osteomyelitis and amputation [3-6]. The bone loss size, together with the absence of infection, are
SC R
two key factors in the surgical treatment of segmental bone loss. Bone defects less than 4-6 cm may be treated with autologous cancellous bone grafting, in patients without signs of infection, after the wound has healed. On the other hand, bone defects greater than 6 cm may be amenable to treatment with vascularized or non-vascularized fibular graft [5] or internal transport with an external fixator
U
(Ilizarov technique) [7].
N
Masquelet technique, i.e. the use of a temporary antibiotic cement spacer followed by grafting
management of post-traumatic bone defects [8].
A
within this space confirmed by an induced biomembrane, is a valid treatment strategy in the
M
Moreover, the Reaming Irrigation Aspiration (RIA) system has been recently described as a harvest technique of cortico-cancellous intramedullary femoral bone graft [9].
ED
This case report describes the use of Masquelet technique, in association with the use of the RIA system, in the management of a non-infected open complex fracture of the distal tibia with severe
CC E
PT
bone and soft tissue loss.
Case Report:
A 33-years-old woman is brought into our Emergency Department, after being hit by a car. This pedestrian polytrauma showed an open complex fracture of the right distal tibia, type 43-A3.3
A
according the Arbeitsgem-einschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification system (Figure-1), with concomitant ipsilateral bifocal peroneal fracture, minor head injury and a lacerated contused wound of the occipital region (Injury Severity Score, ISS=18). Broad-spectrum antibiotics were administered at the Emergency Department. Clinical examination of the right leg showed a type IIIB open distal tibia fracture according to Gustilo-Anderson [11], with an open laceration of about 6 cm of the skin with proximal apex in the 2
popliteal region and a distal degloving soft-tissue injury, developing deep to the fascial plane (Figure-2). In the patient’s past medical history, bulimia nervosa was reported. The patient underwent damage control surgery, using a tibial-calcaneal external fixator with two tibial pins, a metatarsal pin and a calcaneal pin (Figure-3). A concomitant copious wound washing, using about nine litres of 0.9% Sodium Chloride solution, was performed. The subsequent wound exploration showed nor vascular neither tendon injuries. Vacuum-Assisted wound Closure (VAC) therapy was used to manage the open wound.
IP T
On day four post-trauma, a second look and a surgical toilette of the open wound was performed. The soft-tissues looked well perfused and vital; three wound swabs were taken for cultural tests and
SC R
a copious wound washing was performed. The fracture site exploration revealed the presence of three big avascular diaphyseal fragments that were removed, thus leaving a bone loss of about 6 cm. The use of VAC therapy was confirmed. The patient had no fever; wound swabs were negative for soft tissue infection, in absence of serologic markers of acute infection.
U
On sixteen post-trauma day, the patient underwent an endomedullary nail fixation of the fracture,
N
using an Unrimed Tibial Nail (UTN; 345x10mm; De Puy Synthes, Raynham, Massachusetts, USA). A copious washing and a surgical toilette of the open wound were performed; no signs of infection
A
were observed. A temporary gentamicin-loaded cement spacer (polymethylmethacrylate, PMMA)
M
was inserted around the nail, at the bone loss site, in order to perform a subsequent Masquelet technique (Figure-3). A surgical suture was then performed, in order to create a biologic chamber
was allowed after surgery.
ED
around the cement spacer. Advanced surgical wounds dressing were used. Partial weight bearing
PT
On thirty day post-trauma, surgical stitches were removed and a good wound healing was detected. The patient underwent a clinical and radiologic follow-up; at 3-months follow-up, a tibial malalignment was found. Consequently, the patient underwent a new surgical procedure consisting
CC E
of previous endomedullary nail removal and bone grafting of the fracture site according to Masquelet [8].
A new surgical incision on the old scar was performed in order to remove the UTN nail; a new
A
procedure of closed reduction and internal fixation with an endomedullary Expert tibial nail (De Puy Synthes, Raynham, Massachusetts, USA) was performed. Two poller screws were used to correctly reduce the fracture. A new surgical incision on the old scar, in the distal leg, was also performed, in order to open the biologic chamber and remove the cement spacer. A bone graft of the fracture site was performed using the Reaming Irrigation Aspiration (RIA) system (De Puy Synthes, Raynham, Massachusetts, USA); intramedullary reaming was performed in the ipsilateral femur. 3
The patient underwent a subsequent clinical and radiological follow-up. At thirteen-month posttrauma, the fracture healing was observed on X-rays (Figure-4); the patient referred no pain during the activity of daily leaving and an American Orthopaedic Foot and Ankle Society (AOFAS) score of 92% was recorded.
Discussion:
IP T
The treatment of open fractures of the distal tibia is a challenging topic in Orthopaedic and Traumatology, particularly when the fracture involves a segmental bone loss. Several treatment
SC R
options have been described for such a kind of injuries, including vascularized/avascularised fibular graft [6], cancellous bone graft [14] and bone transport [7].
Bone graft techniques should be avoided in acute; they must be be delayed, respect to the fracture fixation, in order to decrease the infection risk and, at the same time, prevent the graft resorption
U
[11].
N
Bone transport with an external fixator could be effective in the management of open fractures with segmental bone loss, but the patient’s compliance is mandatory for the success of this treatment.
M
persist even after removal of the devices [12].
A
Moreover, external fixation could have a negative impact on the patients' mental health, which may
Masquelet et al, in 2000, described a surgical technique that combines induced membranes and
ED
bone autografts [8]. This technique involves the use of a temporary cement spacer followed by grafting within this space confirmed by an induced biomembrane. It should be noted that cement
PT
spacers provide a temporary structural support in bone loss defects, create a well-defined gap, that will be further filled with the bone graft, thus preventing the fibrous tissue ingrowth and promote the formation of a biomembrane [13; 14]. In traumatic wounds antibiotic loaded cement spacers are
CC E
used; they have the advantage to release antibiotic to the soft tissue, thus they should reduce the fracture site infection risk [13]. Masquelet and Bengue argued that the biologic membrane enhances the graft vascularity and
A
corticalization, preventing, at the same time, the bone graft resorption [14]. It is also reported that a membrane needs at least four weeks to reach the adequate maturation that makes it suitable for grafting. Pellissier et al have observed that the induced membranes produce vascular and osteoconductive factors, which enhance bone regeneration [4;16]. We described a case of a 33 years-old woman with a 43-A3.3 open tibial fracture, that was managed with acute temporary external fixation and VAC therapy. Damage control surgery has the advantages of limiting ongoing haemorrhage and soft-tissue injury, through an efficient fracture 4
stabilization, and minimizing additional physiologic insult [17]. VAC therapy is used in the acute management of open fractures since it reduces infection risk and wound area and causes healthy granulation tissue to appear [18]. No signs of local infection were detected in the case described, thus an internal fixation with an endomedullary nail was performed. The tibial misalignment observed at three months follow-up could depend on the fracture pattern, that presented a wide bone loss and a relatively small distal tibia fragment.
IP T
Masquelet technique revealed effective in the management of the segmental bone loss observed in this patient. This technique, as described by Masquelet [8] relied on the placement of morselized
SC R
cancellous autograft harvested from the iliac crests within the biomembrane lined defect [4;8]. In this case, we used the RIA system to obtain autologous bone from the femoral canal.
The RIA system was originally developed to decrease the incidence of osseous thermal necrosis and fat embolism associated with intramedullary reaming of long bones in traumatic injuries, since it
U
provides a continuous irrigation and suction [19]. Recently, the use of RIA has been expanded to
N
harvest autologous bone, because of its ability to capture bone graft and marrow aspirate [19]. The use of autologous femoral bone has many advantages, since it is reported that femoral
A
cancellous has a higher concentration of several growth factors (including fibroblast growth factor-
M
alpha, platelet derived growth factor, insulin-like growth factor 1, Transforming Growth Factor-1, and Bone Morphogenic Bone Protein-2) compared with iliac crest and platelet preparations [20].
ED
At thirteen months after trauma, the fracture and soft tissue were completely heled and the patients, in absence of local or general complication.
PT
The surgical strategy described resulted successful in the management of this non-infected open
CC E
complex fracture of the distal tibia with severe bone and soft tissue loss.
Conclusion:
The Masquelet technique, i.e. delayed bone grafting after initial placement of a cement spacer, in association with the use of RIA system is a valid technique in the treatment of open fractures with
A
segmental bone loss. It is a valid alternative to bone transport with external fixator, since it does not affect the patient’s mental health.
Conflict of interest None of the authors has any conflicts of interest to declare. No funding was received in support of this study. All procedures performed were in accordance with the ethical standards of the 5
institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
The manuscript was approved by all authors for publication. I would like to declare on behalf of my co-authors that the work described, including data and figures has not been published previously, and is not under consideration for publication elsewhere, in whole or in part.
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All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the
be submitted.
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A
N
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The patient provided consent for publication of this case report.
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article or revising it critically for important intellectual content, (3) final approval of the version to
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References: 1. F Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg Br 1998;80:243–8. 2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691– 7. 3. Elniel AR, Giannoudis PV. Open fractures of the lower extremity. Current insights into theirmanagement and clinical outcomes. EFORT Open Rev 2018;3 DOI: 10.1302/2058-
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241.3.170072.
4. Park J, Yang KH. Treatment of an open distal tibia fracture with segmental bone loss in
2012;132:1121–1124. DOI 10.1007/s00402-012-1523-6.
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combination with a closed proximal tibia fracture: a case report. Arch Orthop Trauma Surg.
5. Keating JF, Simpson AH, Robinson CM. The management of fractures with bone loss. J Bone Joint Surg Br. 2005;87(2):142–150.
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6. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue
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defects in traumatic lower extremities. Plast Reconstr Surg. 2004; 114(6):1457–1466. 7. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-
A
union of the tibia associated with infection. J Bone Joint Surg Am. 2004; 77(6):835–846.
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8. Masquelet AC, Fitoussi F, Begue T, et al. Reconstruction of the long bones by the induced membrane and spongy autograft, Annales de Chirurgie Plastique et Esthetique, 2000; 45(3):
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346–353.
9. Masquelet AC, Benkoa PE, Mathevonb H. Harvest of cortico-cancellous intramedullary
PT
femoral bone graft using the reamer-irrigator-aspirator (RIA). Orthopaedics & Traumatology: Surgery & Research. 2012; 98:227—232. 10. Kim PH, Leopold SS. Gustilo-Anderson Classification. Clin Orthop Relat Res. 2012 Nov;
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470(11): 3270–3274.
11. McCall TA, Brokaw DS, Jelen BA et al. Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series. Orthopedic Clinics of North
A
America. 2010: 41(1) 63–73.
12. Wong T, Lau T, Li X et al. Masquelet Technique for Treatment of Posttraumatic Bone Defects.
Scientific
World
Journal
2014,
Article
ID
710302.
http://dx.doi.org/10.1155/2014/710302. 13. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects,” Orthopedic Clinics of North America. 2010 41(1) 27–37. 14. Chacha PB. Vascularised pedicular bone grafts. Int Orthop. 1984. 8(2):117–138. 7
15. Abulaiti A, Yilihamu Y, Yasheng I et al. The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect. Injury. 2017 Dec;48(12):2842-2846. doi: 10.1016/j.injury.2017.10.036. 16. Pelissier P, Masquelet AC, Bareille R. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. Journal of Orthopaedic Research. 2004.22: 73–79. 17. D'Alleyrand JC, O'Toole RV. The evolution of damage control orthopedics: current evidence
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and practical applications of early appropriate care. Orthop Clin North Am. 2013 Oct;44(4):499-507. doi: 10.1016/j.ocl.2013.06.004.
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18. Blum ML, Esser M, Richards M et al. Negative pressure wound therapy reduces deep infection rate in open tibial fractures. J. Orthop. Trauma. 2012. 26:499–505.
19. Billow D, Khlopas A, Chughtai M. The Reamer-Irrigator-Aspirator System: A Review. Surg Technol Int. 2016 Oct 26;29:287-294.
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20. Schmidmaier G, Herrmann S, J. Green et al. Quantitative assessment of growth factors in
A
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A
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reaming aspirate, iliac crest, and platelet preparation. Bone. 2006. 39:5;156–1163.
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Figure Legend:
Figure-1 A and B: Pre-operative X-ray of the right leg.
Figure-2: Clinical photo showing the open distal tibia fracture with severe soft-tissue loss.
Figure-3 A and B: X-ray of the right leg performed at 13 months after trauma. A complete fracture
A
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PT
ED
M
A
N
U
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IP T
healing is detectable.
9
A ED
PT
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A E
PT
CC E
EP
CC
A
A ED
PT
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M
N U S
A ED
PT
CC E A
M
N U S
S0020-1383(18)30707-1 https://doi.org/10.1016/j.injury.2018.11.039 JINJ 7952
To appear in:
Injury, Int. J. Care Injured
Received date: Revised date: Accepted date:
11 August 2018 19 November 2018 23 November 2018
Please cite this article as: Demitri S, Vicenti G, Carrozzo M, Bizzoca D, De Franceschi D, Moretti B, The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A Case Report, Injury (2018), https://doi.org/10.1016/j.injury.2018.11.039 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A Case Report Silvio Demitri1, Giovanni Vicenti2, Massimiliano Carrozzo2, Davide Bizzoca2, Dania De Franceschi1, Biagio Moretti2 Clinic of Orthopaedics, Academic Hospital of Udine, Italy. School of Medicine, University of Bari “Aldo Moro”- AOU Consorziale “Policlinico”, Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic and Unit, Bari, Italy. Corresponding author: Giovanni Vicenti, M.D: Department of Basic Medical Sciences, Neuroscience and Sense Organs. Orthopaedic Clinic. School of Medicine, University of Bari “Aldo Moro”. AOU Consorziale Policlinico. Piazza Giulio Cesare 11, 70100 Bari, Italy. Tel: +39 0805593402 E-mail: [email protected] 1
SC R
IP T
2
Abstract:
U
The treatment of open distal tibia fractures remains challenging, particularly when the fracture
N
involves severe soft tissue damage and segmental bone loss.
We present the case of a 33-year-old woman who sustained an open distal tibia fracture type 43-
A
A3.3, with segmental bone loss, and a closed bifocal fibular fracture.
M
The fractures were initially fixed with a temporary external fixator. The open distal tibial fracture underwent an endomedullary nailing on day six post-trauma, while the segmental bone loss was
ED
refilled with a temporary cement spacer, in order to create a biologic chamber, according to the technique by Masquelet et al.
PT
At three months post-trauma, the temporary cement spacer was removed and the bone loss was filled with an autologous bone graft obtained with the Reaming Irrigation Aspiration (RIA) system. The fracture successfully healed at 13 months post-trauma.
CC E
Masquelet technique, in association with the RIA system, represents a valid strategy in the treatment of non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss.
A
Key-words: Masquelet technique; case report; Reaming Irrigation Aspiration (RIA); open distal tibia fracture; endomedullary nail.
1
Introduction: Open distal tibia fractures, including extraarticular fractures of the metaphysis and intra-articular plafond fractures, are a quite common injury with a reported annual incidence of about 3.4 per 100,000 [1-2]. This kind of fracture commonly results from high-energy trauma, i.e. falls from heights, pedestrian or motor vehicle accidents [2-3]. Because of the subcutaneous location of the tibia, segmental bone defects could be observed in 68-
IP T
79% of distal tibia fractures [4-6]. The treatment of such a kind of fractures is a big challenge, since it may cause a long-term morbidity in terms of soft tissue necrosis, surgical site infection, osteomyelitis and amputation [3-6]. The bone loss size, together with the absence of infection, are
SC R
two key factors in the surgical treatment of segmental bone loss. Bone defects less than 4-6 cm may be treated with autologous cancellous bone grafting, in patients without signs of infection, after the wound has healed. On the other hand, bone defects greater than 6 cm may be amenable to treatment with vascularized or non-vascularized fibular graft [5] or internal transport with an external fixator
U
(Ilizarov technique) [7].
N
Masquelet technique, i.e. the use of a temporary antibiotic cement spacer followed by grafting
management of post-traumatic bone defects [8].
A
within this space confirmed by an induced biomembrane, is a valid treatment strategy in the
M
Moreover, the Reaming Irrigation Aspiration (RIA) system has been recently described as a harvest technique of cortico-cancellous intramedullary femoral bone graft [9].
ED
This case report describes the use of Masquelet technique, in association with the use of the RIA system, in the management of a non-infected open complex fracture of the distal tibia with severe
CC E
PT
bone and soft tissue loss.
Case Report:
A 33-years-old woman is brought into our Emergency Department, after being hit by a car. This pedestrian polytrauma showed an open complex fracture of the right distal tibia, type 43-A3.3
A
according the Arbeitsgem-einschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification system (Figure-1), with concomitant ipsilateral bifocal peroneal fracture, minor head injury and a lacerated contused wound of the occipital region (Injury Severity Score, ISS=18). Broad-spectrum antibiotics were administered at the Emergency Department. Clinical examination of the right leg showed a type IIIB open distal tibia fracture according to Gustilo-Anderson [11], with an open laceration of about 6 cm of the skin with proximal apex in the 2
popliteal region and a distal degloving soft-tissue injury, developing deep to the fascial plane (Figure-2). In the patient’s past medical history, bulimia nervosa was reported. The patient underwent damage control surgery, using a tibial-calcaneal external fixator with two tibial pins, a metatarsal pin and a calcaneal pin (Figure-3). A concomitant copious wound washing, using about nine litres of 0.9% Sodium Chloride solution, was performed. The subsequent wound exploration showed nor vascular neither tendon injuries. Vacuum-Assisted wound Closure (VAC) therapy was used to manage the open wound.
IP T
On day four post-trauma, a second look and a surgical toilette of the open wound was performed. The soft-tissues looked well perfused and vital; three wound swabs were taken for cultural tests and
SC R
a copious wound washing was performed. The fracture site exploration revealed the presence of three big avascular diaphyseal fragments that were removed, thus leaving a bone loss of about 6 cm. The use of VAC therapy was confirmed. The patient had no fever; wound swabs were negative for soft tissue infection, in absence of serologic markers of acute infection.
U
On sixteen post-trauma day, the patient underwent an endomedullary nail fixation of the fracture,
N
using an Unrimed Tibial Nail (UTN; 345x10mm; De Puy Synthes, Raynham, Massachusetts, USA). A copious washing and a surgical toilette of the open wound were performed; no signs of infection
A
were observed. A temporary gentamicin-loaded cement spacer (polymethylmethacrylate, PMMA)
M
was inserted around the nail, at the bone loss site, in order to perform a subsequent Masquelet technique (Figure-3). A surgical suture was then performed, in order to create a biologic chamber
was allowed after surgery.
ED
around the cement spacer. Advanced surgical wounds dressing were used. Partial weight bearing
PT
On thirty day post-trauma, surgical stitches were removed and a good wound healing was detected. The patient underwent a clinical and radiologic follow-up; at 3-months follow-up, a tibial malalignment was found. Consequently, the patient underwent a new surgical procedure consisting
CC E
of previous endomedullary nail removal and bone grafting of the fracture site according to Masquelet [8].
A new surgical incision on the old scar was performed in order to remove the UTN nail; a new
A
procedure of closed reduction and internal fixation with an endomedullary Expert tibial nail (De Puy Synthes, Raynham, Massachusetts, USA) was performed. Two poller screws were used to correctly reduce the fracture. A new surgical incision on the old scar, in the distal leg, was also performed, in order to open the biologic chamber and remove the cement spacer. A bone graft of the fracture site was performed using the Reaming Irrigation Aspiration (RIA) system (De Puy Synthes, Raynham, Massachusetts, USA); intramedullary reaming was performed in the ipsilateral femur. 3
The patient underwent a subsequent clinical and radiological follow-up. At thirteen-month posttrauma, the fracture healing was observed on X-rays (Figure-4); the patient referred no pain during the activity of daily leaving and an American Orthopaedic Foot and Ankle Society (AOFAS) score of 92% was recorded.
Discussion:
IP T
The treatment of open fractures of the distal tibia is a challenging topic in Orthopaedic and Traumatology, particularly when the fracture involves a segmental bone loss. Several treatment
SC R
options have been described for such a kind of injuries, including vascularized/avascularised fibular graft [6], cancellous bone graft [14] and bone transport [7].
Bone graft techniques should be avoided in acute; they must be be delayed, respect to the fracture fixation, in order to decrease the infection risk and, at the same time, prevent the graft resorption
U
[11].
N
Bone transport with an external fixator could be effective in the management of open fractures with segmental bone loss, but the patient’s compliance is mandatory for the success of this treatment.
M
persist even after removal of the devices [12].
A
Moreover, external fixation could have a negative impact on the patients' mental health, which may
Masquelet et al, in 2000, described a surgical technique that combines induced membranes and
ED
bone autografts [8]. This technique involves the use of a temporary cement spacer followed by grafting within this space confirmed by an induced biomembrane. It should be noted that cement
PT
spacers provide a temporary structural support in bone loss defects, create a well-defined gap, that will be further filled with the bone graft, thus preventing the fibrous tissue ingrowth and promote the formation of a biomembrane [13; 14]. In traumatic wounds antibiotic loaded cement spacers are
CC E
used; they have the advantage to release antibiotic to the soft tissue, thus they should reduce the fracture site infection risk [13]. Masquelet and Bengue argued that the biologic membrane enhances the graft vascularity and
A
corticalization, preventing, at the same time, the bone graft resorption [14]. It is also reported that a membrane needs at least four weeks to reach the adequate maturation that makes it suitable for grafting. Pellissier et al have observed that the induced membranes produce vascular and osteoconductive factors, which enhance bone regeneration [4;16]. We described a case of a 33 years-old woman with a 43-A3.3 open tibial fracture, that was managed with acute temporary external fixation and VAC therapy. Damage control surgery has the advantages of limiting ongoing haemorrhage and soft-tissue injury, through an efficient fracture 4
stabilization, and minimizing additional physiologic insult [17]. VAC therapy is used in the acute management of open fractures since it reduces infection risk and wound area and causes healthy granulation tissue to appear [18]. No signs of local infection were detected in the case described, thus an internal fixation with an endomedullary nail was performed. The tibial misalignment observed at three months follow-up could depend on the fracture pattern, that presented a wide bone loss and a relatively small distal tibia fragment.
IP T
Masquelet technique revealed effective in the management of the segmental bone loss observed in this patient. This technique, as described by Masquelet [8] relied on the placement of morselized
SC R
cancellous autograft harvested from the iliac crests within the biomembrane lined defect [4;8]. In this case, we used the RIA system to obtain autologous bone from the femoral canal.
The RIA system was originally developed to decrease the incidence of osseous thermal necrosis and fat embolism associated with intramedullary reaming of long bones in traumatic injuries, since it
U
provides a continuous irrigation and suction [19]. Recently, the use of RIA has been expanded to
N
harvest autologous bone, because of its ability to capture bone graft and marrow aspirate [19]. The use of autologous femoral bone has many advantages, since it is reported that femoral
A
cancellous has a higher concentration of several growth factors (including fibroblast growth factor-
M
alpha, platelet derived growth factor, insulin-like growth factor 1, Transforming Growth Factor-1, and Bone Morphogenic Bone Protein-2) compared with iliac crest and platelet preparations [20].
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At thirteen months after trauma, the fracture and soft tissue were completely heled and the patients, in absence of local or general complication.
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The surgical strategy described resulted successful in the management of this non-infected open
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complex fracture of the distal tibia with severe bone and soft tissue loss.
Conclusion:
The Masquelet technique, i.e. delayed bone grafting after initial placement of a cement spacer, in association with the use of RIA system is a valid technique in the treatment of open fractures with
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segmental bone loss. It is a valid alternative to bone transport with external fixator, since it does not affect the patient’s mental health.
Conflict of interest None of the authors has any conflicts of interest to declare. No funding was received in support of this study. All procedures performed were in accordance with the ethical standards of the 5
institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
The manuscript was approved by all authors for publication. I would like to declare on behalf of my co-authors that the work described, including data and figures has not been published previously, and is not under consideration for publication elsewhere, in whole or in part.
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All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the
be submitted.
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The patient provided consent for publication of this case report.
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article or revising it critically for important intellectual content, (3) final approval of the version to
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Figure Legend:
Figure-1 A and B: Pre-operative X-ray of the right leg.
Figure-2: Clinical photo showing the open distal tibia fracture with severe soft-tissue loss.
Figure-3 A and B: X-ray of the right leg performed at 13 months after trauma. A complete fracture
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healing is detectable.
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