D Krappinger1, R A Lindtner, M Zegg, A Dal Pont, B Huber. 1. Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich, dietmar@krappinger.eu.
Abstract
OBJECTIVE: Treatment of large dia- and metaphyseal bone defects (> 3 cm) with two surgical interventions with an interval of 4-8 weeks. INDICATIONS: Dia- and metaphyseal bone defects predominantly of the lower extremity. CONTRAINDICATIONS: Intraarticular bone defects, persisting bone infection or osteomyelitis, insufficient soft tissue coverage in the region of the bone defect, osteoporosis. SURGICAL TECHNIQUE: First surgical intervention: thorough bone debridement and soft tissue coverage, implantation of a cement spacer into the bone defect for the induction of a synovial foreign-body membrane, internal or external fixation. Second surgical intervention: removal of the cement spacer and filling of the bone defect with autologous cancellous bone graft, optionally internal fixation after initial external fixation. POSTOPERATIVE MANAGEMENT: Partial to full weight-bearing after the first surgical intervention depending on pain. Partial weight-bearing (max. 15 kg) after the second surgical intervention, until radiological signs of a remodeling of the regenerate bone occur. Usually no implant removal. RESULTS: A total of 6 patients (4 men, 2 women) aged 15-66 years with average bone defects of 7 cm (range 4-10 cm) were treated using the Masquelet technique. There were 2 aseptic femoral nonunions and 4 tibial nonunions (2 septic and 2 aseptic nonunions). One case was a periprosthetic tibial bone defect. Bone stabilization after debridement was performed using ring fixators on the tibia and an intramedullary nail and a locking plate on the femur, respectively. The second surgical intervention was performed after 6-9 weeks. In 3 of the 4 tibial cases, internal fixation was performed during this intervention. The iliac crest and the RIA (reamer-irrigator-aspirator) technique were used for cancellous bone grafting. Amputation after breakage of the plate was necessary in the patient with the periprosthetic bone defect. Nonunion at the docking site required cancellous bone grafting in 1 patient. All 5 patients were able to perform full weight-bearing without pain after 6 months. The Ilizarov fixator was removed 5 months after the second surgical intervention in a 15-year-old patient. None of the other implants were removed.
OBJECTIVE: Treatment of large dia- and metaphyseal bone defects (> 3 cm) with two surgical interventions with an interval of 4-8 weeks. INDICATIONS: Dia- and metaphyseal bone defects predominantly of the lower extremity. CONTRAINDICATIONS: Intraarticular bone defects, persisting bone infection or osteomyelitis, insufficient soft tissue coverage in the region of the bone defect, osteoporosis. SURGICAL TECHNIQUE: First surgical intervention: thorough bone debridement and soft tissue coverage, implantation of a cement spacer into the bone defect for the induction of a synovial foreign-body membrane, internal or external fixation. Second surgical intervention: removal of the cement spacer and filling of the bone defect with autologous cancellous bone graft, optionally internal fixation after initial external fixation. POSTOPERATIVE MANAGEMENT: Partial to full weight-bearing after the first surgical intervention depending on pain. Partial weight-bearing (max. 15 kg) after the second surgical intervention, until radiological signs of a remodeling of the regenerate bone occur. Usually no implant removal. RESULTS: A total of 6 patients (4 men, 2 women) aged 15-66 years with average bone defects of 7 cm (range 4-10 cm) were treated using the Masquelet technique. There were 2 aseptic femoral nonunions and 4 tibial nonunions (2 septic and 2 aseptic nonunions). One case was a periprosthetic tibial bone defect. Bone stabilization after debridement was performed using ring fixators on the tibia and an intramedullary nail and a locking plate on the femur, respectively. The second surgical intervention was performed after 6-9 weeks. In 3 of the 4 tibial cases, internal fixation was performed during this intervention. The iliac crest and the RIA (reamer-irrigator-aspirator) technique were used for cancellous bone grafting. Amputation after breakage of the plate was necessary in the patient with the periprosthetic bone defect. Nonunion at the docking site required cancellous bone grafting in 1 patient. All 5 patients were able to perform full weight-bearing without pain after 6 months. The Ilizarov fixator was removed 5 months after the second surgical intervention in a 15-year-old patient. None of the other implants were removed.
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