'Intramedullary Nails Yield Superior Results Compared to Plate Fixation when using the Masquelet Technique in the Femur and Tibia.'

OBJECTIVES To determine the optimal fixation method (Intramedullary Nail (IMN) vs. plate fixation (PF)) for treating critical bone defects with the induced membrane technique (IMT), also known as the Masquelet Technique. DESIGN Retrospective cohort study. SETTING Four Level 1 Academic Trauma Centers. PATIENTS/PARTICIPANTS All patients with critical bone defects treated with the IMT, or Masquelet technique, between January 1, 2005 to January 31, 2018. INTERVENTION Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks. MAIN OUTCOME MEASUREMENTS Time to union, number/reason for reoperations, time to full weight bearing, and any complications. RESULTS 121 patients (56 tibias and 65 femurs) were treated with mean follow-up of 22 months (range 12-148 months). IMN were used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with plate fixation (p=0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with plate fixation (p=0.001). Average time to weight bearing occurred at 2.44 months vs 4.63 months for those treated with IMN and plates, respectively (p=0.002). CONCLUSIONS This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The analysis showed that plate fixation is 6.4 times more likely to require multiple grafting procedures (p=.017) and 7.7 times more likely to require reoperation (p=.003) for all causes compared to IMN. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weightbearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weightbearing when using plate fixation. We, therefore, recommend the use of an IMN whenever possible, as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. LEVEL OF EVIDENCE Level 3.