Background: The Masquelet-induced-membrane technique is a commonly used method for treating segmental bone defects. However, there are no established clinical standards for management of the induced membrane before grafting. Questions/purposes: Two clinically based theories were tested in a chronic caprine tibial defect model: (1) a textured spacer that increases the induced-membrane surface area will increase bone regeneration; and (2) surgical scraping to remove a thin tissue layer of the inner induced-membrane surface will enhance bone formation. Methods: Thirty-two skeletally mature female goats were assigned to four groups: smooth spacer with or without membrane scraping and textured spacer with or without membrane scraping. During an initial surgical procedure (unilateral, left tibia), a defect was created excising bone (5 cm), periosteum (9 cm), and muscle (10 g). Segments initially were stabilized with an intramedullary rod and an antibiotic-impregnated polymethylmethacrylate spacer with a smooth or textured surface. Four weeks later, the spacer was removed and the induced-membrane was either scraped or left intact before bone grafting. Bone formation was assessed using micro-CT (total bone volume in 2.5-cm central defect region) as the primary outcome; radiographs and histologic analysis as secondary outcomes, with the reviewer blinded to the treatment groups of the samples being assessed 12 weeks after grafting. All statistical tests were performed using a linear mixed effects model approach. Results: Micro-CT analysis showed greater bone formation in defects with scraped induced membrane (mean, 3034.5 mm 3 ; median, 1928.0 mm 3 ; quartile [Q]1–Q3, 273.3–2921.1 mm 3 ) compared with defects with intact induced membrane (mean, 1709.5 mm 3 ; median, 473.8 mm 3 ; Q1–Q3, 132.2–1272.3 mm 3 ; p = 0.034). There was no difference in bone formation between textured spacers (mean, 2405.5 mm 3 ; median, 772.7 mm 3 ; Q1–Q3, 195.9–2743.8 mm 3 ) and smooth spacers (mean, 2473.2 mm 3 ; median, 1143.6 mm 3 ; Q1–Q3, 230.2–451.1 mm 3 ; p = 0.917). Conclusions: Scraping the induced-membrane surface to remove the innermost layer of the induced-membrane increased bone regeneration. A textured spacer that increased the induced-membrane surface area had no effect on bone regeneration. Clinical Relevance: Scraping the induced membrane during the second stage of the Masquelet technique may be a rapid and simple means of improving healing of segmental bone defects, which needs to be confirmed clinically.
Bibliographical noteFunding Information:
We thank Cynthia Boehm BS, Wesley Bova BS, Maha Qadam PhD, Venkata Mantripragada PhD, and Terry Zachos MD (all from Biomedical Engineering, Cleveland Clinic) for technical assistance during surgery; Kimerly Powell PhD (Department of Biomedical Informatics, Ohio State University) and Justin Jeffery PhD (Small Animal Imaging Facility, University of Wisconsin) for help with micro-CT processing and analysis; Ferenc Toth DVM, Elizabeth Marchant DVM, and Channing Bancroft DVM (all from the Department of Veterinary Population Medicine, University of Minnesota) for help with histology processing and analysis; and John Tra PhD (Orthopaedics Department, Walter Reed National Military Medical Center) for assistance with statistical analysis. This work was funded by the Congressionally Directed Medical Research Programs Peer Reviewed Orthopaedic Research Program grant Award # W81XWH-13-2-0086 (GFM).
This work was funded by the Congressionally Directed Medical Research Programs Peer Reviewed Orthopaedic Research Program grant Award # W81XWH-13-2-0086 (GFM). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use. Each author certifies that his or her institution approved the animal protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. Some of the authors (JCA and JF) are employees of the US Government. This work was prepared as part of their official duties. Title 17U.S.C.§105 provides that ‘‘Copyright protection under this title is not available for any work of the United States Government.’’ Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense, nor the US Government. This work was performed at Cleveland Clinic, Cleveland, OH, USA.
J. E. Bechtold Department of Orthopaedic Surgery, Minneapolis Medical Research Foundation and University of Minnesota, Saint Paul, MN, USA