Management of recalcitrant osteomyelitis and segmental bone loss of the forearm with the Masquelet technique

Infected nonunions of the forearm, although rare, can complicate fracture management and significantly impair function. Complex bone defects are difficult to address, for which some surgeons advocate the use of vascularized fibular grafts. Alternatively, the technique of using induced membranes as a scaffold for cancellous bone grafting as described by Masquelet and Begue (2010) offers various advantages. The membrane provides a separate compartment that allows for the implantation of autologous bone graft, minimizes its resorption, and prevents soft tissue interposition. The surgical technique was initially described as a two-stage process (Masquelet and Begue, 2010), but usually requires three procedures to account for initial debridement of grossly contaminated wounds. In the first stage, a polymethyl methacrylate spacer mixed with antibiotics is inserted into the bone defect. The bone is then stabilized with a single plate and screws, bridging the defect. The second stage is typically performed after 1 or 2 months to allow full development of the induced membrane. The spacer is removed and, with special care taken to maintain the membrane, the defect is packed with bone graft. We report the results from a consecutive series of seven patients (three males and four females) who were referred to the senior author (F.A.N. Sr.) with infected forearm nonunions between 2004 and 2013 (Table 1). Mean age of the patients was 47.1 years (range 32 to 74) at time of referral. Prior to referral, the patients underwent an average of 1.57 surgeries (range 1 to 3). The mean lengths of the radial and ulnar defects were 5.8 cm (SD 1.7) and 5.5 cm (SD 1.6), respectively. The Masquelet technique was used to treat the infected nonunions as previously described for the upper extremity (Micev et al., 2015). During spacer implantation, the cement was measured to come into contact with the bone ends, but was not introduced into the medullary canal. Between this surgery and the final stage, patients had no lifting or activity restrictions. In the next stage, morselized iliac crest bone graft was sequentially packed into a 12-mL syringe, which closely matches the diameter of the diaphyseal bone, until the necessary length of graft was attained. Impacting the bone graft in the syringe maximizes its concentration to reduce the risk of resorption. Postoperatively, patients were referred to physical therapy and were restricted to lifting 5 kg at maximum and no contact sports for 3 months. For the Masquelet reconstruction, patients underwent an average of 3.43 surgeries (SD 1.27). Mean follow-up was 86.7 months (range 41 to 150) from initial referral. Bony union was determined clinically and based on radiographic evidence of graft remodelling. One patient required re-grafting due to graft resorption diagnosed on follow-up radiographs. The decision for reoperation was made to prevent potential delayed union. Successful healing of the infected nonunions was achieved in all patients. At latest follow-up, QuickDASH scores improved significantly compared with the preoperative assessment (mean 44.4 versus 14.4, p < 0.001). Patients regained functional forearm pronation (62.1°, 82.0% of uninjured side), supination (70.0°, 88.7%), wrist extension (62.5°, 76.5%), wrist flexion (50.8°, 71.8%), elbow extension (–5.7°, 96.8%), and elbow flexion (122.9°, 97.2%). Grip strength recovered to 85.2% of the uninjured side at latest follow-up (mean 32.9 kg versus 38.6 kg). All patients were cleared for unrestricted activity, and four of the six patients who were previously employed returned to their jobs. One patient qualified for partial disability due to the length of recovery, but was able to return to work in a less physically demanding job. The other patient was at retirement age and elected to retire. In this series, we revisit a technique more commonly used to treat lower extremity segmental bone defects. Biologically, the spacer induces a foreign body reaction in the development of a membrane rich in growth factors, which serves as an excellent 650171 JHS0010.1177/1753193416650171Journal of Hand Surgery (European Volume)Short report letters research-article2016