Case Study | Volume 7 - Issue 1 | Article DOI :
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Zayed Filali¹,³*, Amine Briki¹,³, Souad Ferjani²,³, Achraf Oueslati⁴,⁵, Slim Haj Mohamed¹,³, and Baha Eddine Cherif¹,³
¹Department of Orthopedic Surgery and Traumatology, Hospital Habib Bourguiba, BP 4100 Medenine, Tunisia
²Department of Radiology, Hospital Habib Bourguiba, BP 4100 Medenine, Tunisia
³University of Sfax Medical School, Tunisia
?Department of Orthopedic Surgery and Traumatology, Military Hospital of Instruction of Tunis, Tunisia
?University Tunis El Manar Medical School, Tunisia
Corresponding Author:
Zayed Filali Department of Orthopedic Surgery and Traumatology, Hospital Habib Bourguiba, BP 4100 Medenine, Tunisia
Keywords
Induced Membrane Technique; Large Bone Defect; Chronic Osteomyelitis; Femoral Diaphysis Fracture; Case Report
Abstract
Introduction and Importance: The management of post traumatic long bone osteomyelitis remains a challenging clinical problem. Multiple methods are described to treat large bone gaps, which are defined as segmental defects > 6 cm. The induced membrane technique de Masquelet constitutes a contribution for bone reconstruction in these cases.
Case Presentation: A 56-year-old man, admitted in March 2023 for proximal left femoral diaphysis fracture due to after-effects of chronic osteomyelitis since 2012. Last septic episode dates back to 2013. The patient did not present any cutaneous or vascular complications. the infectious assessment is negative. The patient underwent emergency immobilization using an external fixator type orthofix, then the fracture was treated using the two-stage induced membrane technique according to Masquelet.
Clinical Discussion: The management of long bone fractures resulting from chronic osteomyelitis remains a challenge. The bone defect after debridement is often significant, its reconstruction is difficult because it requires several techniques and operating times. As used in our case, the induced membrane technique, described for the first time by Masquelet in 1986, is a benefit for these fractures resulting from chronic osteomyelitis where the bone gap after debridement is often significant: gives time to control an infection and poses a reconstruction problem.
Conclusion: Large segmental bone defects can be managed using several methods. The induced membrane technique of bone reconstruction first proposed by Masquelet for large bone defects constitutes the gold standard for two-stage bone reconstruction.
Citation
Filali Z, Briki A, Ferjani S, Oueslati A, Mohamed SH, et al. (2024) Treatment of Post Traumatic Femoral Bone Osteomyelitis Using Induced Membrane Technique: A Case Report. SM J Orthop 7: 6.
INTRODUCTION
The management of posttraumatic long bone osteomyelitis remains a challenging clinical problem. Large segmental bone defects, which are defined as segmental defects > 6 cm, can be managed using several methods [1]. Multiple methods are described to treat large bone gaps, including microsurgical reconstruction with vascularized bone grafts and flap coverage, bone transport with external fixators and megaprosthesis. A two-staged approach using the induced membrane technique by Masquelet has been developed to treat long diaphyseal defects by stabilizing the bone with external fixation, filling the void with a tubular Polymethyl Methacrylate (PMMA) cement spacer to activate formation of a pseudo synovial membrane and replacing the spacer after six weeks with extensive fresh autologous bone grafts [2]. The aim of this case is to evaluate our clinical experience in reconstruction of critical posttraumatic bone defects using an induced membrane technique based on a combination of autologous cancellous bone taken from the iliac crest and cortical bone taken from a free fibula. The work has been reported in line with the SCARE criteria and the revised 2023 SCARE guidelines [3].
CASE PRESENTATION
A 56-year-old man, with medical history of type 2 diabetes and surgical history of a left Peritrochanteric fracture in 2003 osto synthesized by a Dynamic Hip Screw (DHS). The evolution was towards infection on osteosynthesis equipment. The patient underwent removal of the DHS, debridement and intravenous and oral antibiotic therapy. The fracture consolidated with skin healing and the infectious assessment was negative. A septic awakening from chronic osteomyelitis of the left femur was noted in 2012, treated medically, and since then the patient has maintained recovery (Figure 1). In 2023, following a slip in the bathroom, the patient had a displaced diaphyseal fracture at the junction of the upper third and middle third of the left femur, and without cutaneous or vasculo-nervous complications. The infectious assessment was negative. A CT scan confirmed the fracture with a fractured scleral bone but no bone sequestrum (Figure 1). The patient underwent emergency immobilization using an external fixator type Orthofix (Figure 1), then the fracture was treated using the two-stage induced membrane technique according to Masquelet. The first stage involves a radical debridement of fibrosis and sclerotic bone, stabilization with an external fixation, and placement of a polymethylmethacrylate spacer. The bone defect was large measured at 6.5 cm (Figure 2).
Figure 1: A: Antero-posterior and lateral radiographs of the proximal half of the left femur showing sequelae of chronic osteomyelitis.
B: Antero-posterior and lateral radiographs of the left femur showing a simple oblique fracture displaced at the proximal third junction middle third.
C: Antero-posterior and 3/4 radiographs of the left femur showing an external fixation of the fracture with Orthofix.
D: coronal section of a CT scan showing the sclera margins of the fracture and the absence of a sequestrum.
Figure 2 : First stage of induced membrane technique
A: Preoperative clinical photograph demonstrating cement spacer filling the bone gap after debridement.
B: Antero-posterior and lateral radiographs of the left femur showing cement spacer filling the bone gap and external fixation with Orthofix.
The second stage, six weeks later, includes excision of the spacer with respect of the induced membrane and placement of autologous bone graft, combining. The external fixator was removed and internal osteosynthesis was performed using a trochanteric plate with hooks combining screwing and cerclage. The patient received preventive antibiotic therapy intraoperatively (Figure 3). Postoperatively, anticoagulant and analgesic treatment was prescribed, combining a dressing change twice a week and a ban on weight bearing. The radioclinical control was carried out after one month then every three months. The operative consequences were simple and the progression was towards healing of the skin, authorization of support after three months and consolidation of the fracture site has obtained after seven months (Figure 4) and (Figure 5). The infectious results were always negative.
Figure 3 : Second stage of induced membrane technique
A: Preoperative clinical photograph demonstrating a biological chamber of induced membrane.
B: Preoperative clinical photograph showing a 10 cm free fibula graft fused in two.
C: Antero-posterior and lateral radiographs of two bones of the left leg showing the site for harvesting of free fibula graft.
D: Antero-posterior and lateral radiographs of the left femur on post-operative second phase showing the filling of the bone gap with cancellous and cortical graft and fixation by hook plate fixed by screwing and cerclage.
Figure 4 :
A: Antero-posterior and lateral radiographs of the left femur, one month postoperatively showing the beginning of bone callus.
B: Antero-posterior and lateral radiographs of the left femur, seven months postoperatively showing consolidation of the fracture site.
C: Antero-posterior and lateral radiographs of the left femur, twelve months postoperatively showing an excellent bone callus more pronounced in the medial.
D: 3D scan reconstruction confirming bone consolidation twelve months postoperatively.
Figure 5 :
A: Clinical photograph showing stable bipodal support.
B: Clinical photograph showing good skin healing.
C: Clinical photograph showing stable monopod support.
CLINICAL DISCUSSION
The management of long bone fractures resulting from chronic osteomyelitis remains a challenge. These fractures are often with sclerotic edges and the progression towards pseudarthrosis is most often the case regardless of whether the fixation was internal or external. The possibility of a septic awakening must always be investigated clinically and biologically [4]. The bone defect after debridement is often significant, its reconstruction is difficult because it requires several techniques and operating times. The approach is multidisciplinary and patients must be prepared for a long series of multiple surgeries and possible complications. Large segmental bone defects can be managed using several methods: distraction osteogenesis, a free vascularized fibular bone graft or the induced membrane technique [5].
The induced membrane technique, described for the first time by Masquelet in 1986, is a benefit for these fractures resulting from chronic osteomyelitis where the bone gap after debridement is often significant: gives time to control an infection and poses a reconstruction problem. As used in our case, poly methyl methacrylate cement spacer kept in the cavity forms a membrane lined cavity forming a biological chamber for the later grafting. These membranes have a rich capillary network and secretes growth factors and osteoinductive factor as early as 2 weeks. The membrane prevents resorption of the cancellous bone graft in the vascular environment. The membrane promotes also vascularisation and corticalisation of the cancellous bone [5,6]. The lateral prior of this biological chamber is often damaged by the surgical approach and extraction of the spacer as well as the installation of the screwed plate [7]. As in our case we note that the bone callus is important medially while it is thin lateral.
Infection is often controlled during the first stage of the induced membrane technique by good bone and soft tissue debridement and antibiotic therapy adapted according to the bacteriological and anatomopathological results. In our case, the patient has only benefited from per and post-operative antioprophylaxis given that the clinical and biological infectious assessments were negative [8]. As in the literature, consolidation was obtained in our case after seven months postoperatively with total weight bearing on the left lower limb and complete mobility of the ipsilateral hip and knee [9,10].
CONCLUSION
The management of posttraumatic long bone osteomyelitis remains a challenging clinical problem. Large segmental bone defects can be managed using several methods. The induced membrane technique of bone reconstruction first proposed by Masquelet for large bone defects constitutes the gold standard for two-stage bone reconstruction. The suggestion that the membrane also secretes vascular and osteoinductive factors to stimulate bone regeneration encourage the use of the procedure.
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