Aim

For which patients is bone defect reconstruction with the Masquelet-technique after the treatment of osteomyelitis suitable and which results did we have.

Aim

Which patients is bone-defect-reconstruction with the Masquelet-technique suitable and which problems did we see?

For which patients is bone-defect-reconstruction with the Masquelet-technique suitable?

Between 11/2011 and 1/2015 we treated 27 Patients (4 female/ 23 male) with bone-defects up to 150mm after septic complications with the Masquelet-technique.

Reason of the bone defects were infected-non-unions of lower extremity, chronic osteomyelitis, infected knee-arthrodesis, chronic upper-ancle-empyema and infect-defect-non-union of the humerus. On average the patients were 47,5 (18–74) years old. The mean bone-defect-size was 62,6 mm (25–150). 26 of the 27 patients came from other hospitals, where they had up to 20 (mean 4,9) operations caused by the infection. The time before transfer to our hospital was on average 177days (6–720). 25 patients receaved flaps because of soft tissue-defects (7 free flaps, 18 local flaps).

13 patients suffered a polytrauma.

In 5 cases the femur, in 3 cases a knee-arthrodesis, in 18 cases the tibia and in 1 case the humerus was affected by infection resulting in bone defects.

Indication for the Masquelet-technique was low-/incompliance in 10 cases due to higher grade of traumatic brain injury and polytrauma and difficult soft-tissue conditions, in 6 times after problems with segment-transport and in 1 case as dead space management.

Positiv microbial detection succeeded in 19 patients at the first operation although most of the patients underwent long term antibiotic therapy. Mainly we found problematic bacteria. At the time of defect reconstruction with spongious graft we found persistant bacteria in 4 cases.

The first operation aimed treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with an antibiotic loaded cementspacer as well as external fixation. 6–8 weeks later we removed the spacer and filled the defect with autologous bonegraft. In 2 cases we needed 2 bone grafts to fill the defect. In 9 cases we removed the fixateur and stabilized the defect with an internal anglestable plate.

All patients were examined clinically and radiologically every 4–6 weeks in our outpatient-department for osteitis until full weight bearing and later every 3months

In 22 of 27 cases the infection was clinically treated successfully. 5 patients are allowed for full weight bearing (all with secondary internal plates). No patient underwent amputation.

There were 4 recurrences of infection, 9 instabilities needing internal stabilization and further bonegraft.

For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the Masquelet technique is a valuable alternative to the normal autologious spongegraft and to the segmenttransport. Internal fixation seems necessary.

During the therapy of infected pseudarthrosis and arthrodesis in which multiple autologous bone grafts did not result in osseous consolidation and in delayed osseous healing of transport stretches after completion of segmental transport in osteomyelitis patients without acute infection symptoms, mesenchymal stem cells were added to the treatment. This study demonstrates the mid- and long-term results in different application possibilities with good and poor results. The aim is to develop an algorithm in treating bone defects regarding the different biomaterials and implants that exist on the market.

The indication to apply mesenchymal stem cells was the reconstruction of osseous lesions after chronic osteomyelitis, the treatment of pseudarthrosis and the support of osseous growth in segmental transports. Further indications were the absence of adequate amounts of autologous spongiosa, multiple previous operations, risk factors (diabetes, peripheral vascular disease, alcohol and nicotine abuse, etc.) as well as chronic wound healing failure. To obtain the mesenchymal stem cells, we employed two different systems from two companies. Both systems concentrate the mesenchymal stem cells after puncture and aspiration from the pelvic crest. The concentrated stem cells were either mixed with platelet-rich plasma and added to the autologous spongiosa or injected into the area of osseous regeneration after completion of segment transport.

Since 2009, we have applied mesenchymal stem cells to 87patients. The treatment was performed in 73 cases of persisting pseudarthrosis after multiple bone grafts and in 14 cases of delayed osseous healing after segmental transport. The results were evaluated by continuous clinical and radiological examinations in our outpatient clinic.

We found a great variety in our results with a mainly high rate of survival and healing in the autologous bone grafts with mesenchymal stem cells, resulting predominantly in stabilization of the pseudarthrosis. Furthermore a good osseous consolidation was documented in several cases with transport stretches of segmental transports.

However we also had some frustrating results with all the well-known complications of septic surgery.

Our experiences so far, have led to a distinguished therapy-algorithm including all the biomaterials and additives that are used in our hospital.

Overall, the results demonstrate an advantage in the treatment with mesenchymal stem cells, espe-cially in problematic and difficult cases in combination with multiple pre-existing conditions.

The use of mesenchymal stemcells must be included in a general concept regarding all treatment possibilities, it is, however, not a guarantee for successful therapy of osseous lesions after chronic osteomyelitis especially as a single toll mechanism.