SLR - October 2023 - Shulmister
Title: Treatment outcome of the Masquelet technique in 195 infected bone defects-A single-center, retrospective case seriesReference: Frese J, Schulz AP, Kowald B, Gerlach UJ, Frosch KH, Schoop R. Treatment outcome of the Masquelet technique in 195 infected bone defects-A single-center, retrospective case series [published online ahead of print, 2023 Jul 5]. Injury. 2023;54(10):110923. doi:10.1016/j.injury.2023.110923
Level of Evidence: IV
Reviewed By: Jake Shulmister, DPM
Residency Program: Presbyterian Saint Luke’s - Denver, CO
Podiatric relevance: Septic bone defects are a challenging problem for the Podiatric Surgeon. The Masquelet technique is a procedure that can be used to fill these deficits with autologous bone, preventing the need for large allografts or implants. This study presents one of the largest patient cohorts on the procedure, outlines factors that may contribute to full weight and load bearing following the procedure, as well as defines a critical sized defect, past which success is unlikely.
Methods: Septic bone defects of 195 bones, in 171 patients, were treated via the Masquelet technique at a single center, and retrospectively analyzed for factors including size of defect, pathogens isolated, time to weight and load bearing. Indications included defect larger than 3cm, involving at least 2/3 circumference of bone, or previous failed segmental transport. The initial procedure included debridement, taking microbiology samples prior to intiation of intravenous antibiotics which were continued for minimum 5 days, placement of antibiotic impregnated PMMA, and application of external fixation. The secondary procedure was performed 4-6 weeks later, including filling the deficit with autologous iliac crest or proximal tibia, and definitive fixation to include plate or intramedullary rod. Weight bearing was initiated upon radiologic consolidation.
Results: The tibia was the most effected bone at 70%. The mean length of all defects was 59mm. Of cases, 89% utilized an external fixator for primary stabilization. Samples taken during initial procedure did not grow bacteria in 35% of cases, despite clinical signs of infection. Sterile cultures increased to 79% at the second procedure. Pathology samples were only taken if there was suspicion for malignancy. Of patients that had positive bacteria culture at first procedure, 88% went on to full weight bearing. Return to full weight or load bearing, occurred in 89% of patients. Median time from treatment to weight and load bearing was 20 months. Defect size of 61mm was found to be a cut-off point for negative treatment outcome.
Conclusion: The median time to bony union of 20 months, higher than previous literature, suggests the procedure should be reserved for patients that want to be surgically aggressive and give themselves the best chance of achieving an anatomic and functional limb. Despite this long union time, 89% of patients returned to full weight or load bearing, which is reassuring. Due to 88% of patients with a positive culture at initial procedure achieving union, this should not be seen as factor negatively influencing success. Furthermore, the sterile culture incidence of 35% at the first procedure likely represents a blind spot, ie false negative, and the authors support use of minimum 6 weeks of broad spectrum antibiotics in these patients as well. The overall defect size correlated with time to attain full weight and load bearing, and defects measuring more than 62mm should be seen as a critically sized. Patients with larger deficits should be cautioned they are at higher risk for delayed union or failure, and the procedure may want to be avoided all together in deficits of 62mm.