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Introduction: The induced membrane technique was initially described by Masquelet in 1986 as a treatment for tibia non-union. It then became an established method in the management of bone defects.A critical bone defect is defined by a gap larger than 25 mm, and so, has a higher probability of non-union. Many techniques have been described to resolve this problem such as segmental bone transport, free vascular fibula graft, non-vascular fibula graft, autogenous graft, or megaprothesis. Case Report: We present the case of a 37-year-old woman who presented a multi-fragmentary open fracture of the tibia and fibula bilaterally (Gustilo-Anderson III) after a high-velocity car accident. Conclusion: The aim of this article is to demonstrate that the use of a hybrid procedure combining the Masquelet technique with the Ilizarov external fixator and reamer-irrigator-aspirator can be an effective way to treat bone defect in an open tibial fracture classified as a Gustilo-Anderson III.

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Forearm non-union poses a challenge in orthopaedic surgery due to its intricate anatomy and functional significance. This review provides a comprehensive overview of the assessment, diagnosis and management of forearm non-union. Initial evaluation involves a meticulous history, physical examination and imaging studies to identify factors contributing to non-union, including infection. Surgical approaches are discussed, with emphasis on restoring biomechanical stability and promoting bone healing. Treatment options range from autografts to allografts, with considerations for vascularised bone transfers in complex cases. Decision-making strategies are outlined, considering patient-specific factors and individualised treatment plans. Special considerations for specific types of forearm non-unions are addressed, along with postoperative care protocols to optimise healing and functional outcomes. Overall, this review aims to provide clinicians with a comprehensive understanding of forearm non-union management based on current evidence and clinical practice. Level of Evidence: Level V (Therapeutic).

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The treatment of Gustilo-Anderson type III open femoral fracture with large segmental bone defect remains a challenge for orthopedic trauma surgeons. The aims of management are first to prevent the risk of infection and then to reconstruct the bone loss with correct alignment and length. The induced membrane technique (or Masquelet technique) was initially described for tibia nonunion but became over the years an established procedure to treat any kind of large bone defect. The case of a 22-year old male who sustained an open femoral shaft fracture with a circumferential 7-cm bone defect after a car accident is presented. Given the critical size of the bone loss, we chose to manage this patient using a modified-Masquelet technique, in which we stabilized the fracture by an intramedullary femoral nail and filled only the lateral side of the defect with a cement spacer. He went on to have a full and successful union of his fracture 16-weeks after the second stage surgery. The final functional outcomes were excellent allowing the patient to resume all activities without restriction.

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Background: Indications for clavicle fracture fixation have increased dramatically over the last 20 years. Chronic surgical site infection is a particularly severe complication arising from this procedure and can induce nonunion and clinical disability. In such cases, the modified Masquelet technique using an iliac crest autograft (cancellous or tricortical) enables treatment of any bone infection as well as reconstruction of the segmental defect. The aim of this study was to analyze the clinical and radiological results of this procedure at mid-term follow-up. Methods: In this monocentric retrospective study, patients suffering from a septic clavicle nonunion were treated with a modified Masquelet technique and reviewed at a minimum follow-up point of two years. They were clinically assessed using active range of motion, pain score (visual analog scale 0 to 10), Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder value score. Bone healing was measured using standard X-rays and CT scans. Results: Five patients were included (mean age 49 years; range 30 to 62). C. acnes was involved in 80% (n = 4) of these cases. Following the first stage of treatment, the mean bone defect was 3.4 cm (range 2.6 to 6.4 cm). The second stage, performed at a minimum of six weeks (mean 7 ± 1 weeks), used an iliac crest bone autograft in all cases. At a mean follow-up of 5 ± 3 years, the mean pain score was 0.3/10 points (0 to 1), the mean Constant score was 86 points (78 to 96), the mean American Shoulder and Elbow Surgeons score was 98 ± 2%, and the subjective shoulder value score 91 ± 11%, with two "forgotten shoulders" out of five. On CT scan analysis, bone healing was achieved in 100% of cases. One plate (20%) was removed one year following the procedure due to the patient's discomfort; pain and discomfort at the iliac crest site were reported in 5/5 (100%) patients. Conclusion: The modified Masquelet technique using an iliac crest autograft is a reliable and effective technique for treating septic nonunion of the clavicle. It both treats the bony defect and eradicates infection when conducted in association with débridement and antibiotics. In the five cases reported here, this approach had satisfactory results, both subjectively and objectively, with a very low reoperation rate despite persistent pain from iliac bone harvesting.

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Fracture-related infections can be challenging, particularly with concomitant severe bone defects and multi-resistant microorganisms. We present a case of a 42-year-old patient with a fracture-related infection following a war injury from a gunshot, resulting in a 12-cm subtrochanteric segmental bone defect and the detection of four different multi-resistant Gram-negative bacteria. Due to antibiotic drug resistance, treatment with bacteriophages was considered. Phage susceptibility testing revealed the activity of a commercially available bacteriophage cocktail (Intesti bacteriophage, Eliava Institute, Tbilisi, Georgia). This phage cocktail was included in a modified two-stage Masquelet technique. During the first intervention, the bone was debrided and samples for microbiological and phage testing were harvested. The indwelling intramedullary rod was removed, and the bone defect was filled with a PMMA spacer loaded with colistin and the bone stabilized with a plate. During the second procedure, the PMMA spacer was removed and a silver-coated angular stable plate was implanted. The bone defect was filled with a fibular autograft and allograft cancellous bone chips. At the end of the procedure, the Intesti bacteriophage cocktail was injected into a DAC hydrogel and this bacteriophage hydrogel composite was then put onto the angular stable plate. Postoperatively the wound fluid was collected over 72 h, and high-throughput metagenomic sequencing was performed. This showed a time-dependent release of the bacteriophages in the wound fluid, with a relatively high concentration after 12 h, decreasing to DNA copies of 0 after 72 h. Furthermore, we have assessed the release of phages from DAC gel and the effect of DAC gel on the phages in vitro. The results showed a stable and rapid release of phages from the DAC gel (~1×103 PFU/mL). The clinical course of the patient showed no relapse of the infection with good bone consolidation of the bone defect after 1 year without the need for any surgical revision. To the best of our knowledge, this is the first case that shows the detection of bacteriophage DNA copies by high-throughput metagenomics sequencing in a patient with a complex fracture-related infection. Successful treatment of this case encourages further investigation of bacteriophage therapy in patients with complex bone and joint infections.

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BACKGROUND: To evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique. METHODS: We performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement-coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb's knee joint function. RESULTS: The median and quartiles of bone defect length was 7 (4.75-9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9-19) weeks. At a median follow-up of 22 (20-27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6-8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105-120.0)°. CONCLUSIONS: For infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence.

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BACKGROUND/AIM: This study aimed to investigate the structure and functions of the membrane formed around liquid nitrogen-treated bones in the osteogenesis and revitalization of frozen bone using a rat model. MATERIALS AND METHODS: Segmental defects were created in femurs of rats, and resected bones treated with liquid nitrogen [frozen bone (FB) group, n=20] or polymethylmethacrylate (PMMA group; n=20) were implanted as spacers. Histological analysis and quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR) of the membrane around each spacer were performed for bone morphogenetic protein 2 (BMP2), transforming growth factor (TGF)-ß1, and vascular endothelial growth factor (VEGF). Furthermore, in week 2, spacers were removed from both groups (n=5 each), and autologous cancellous bone (ACB) harvested from the ilium was grafted into the defect. Radiological analysis was performed until bone union was observed. RESULTS: In week 2, similar two-layered membrane structures were observed in both groups; these matured into fibrous tissues over time. At each evaluation point, qRT-PCR showed higher expression of all factors in the FB than in the PMMA group. In the ACB graft model, the mean period to bone union and new bone volume were significantly shorter and greater, respectively, in the FB. Chondrocytes invaded the osteotomy site from the membrane in the FB, suggesting that endochondral ossification may occur and be related to osteogenesis. Additionally, fibroblasts and capillaries in the membrane invaded the surface of treated bone in week 2, and osteocytes were observed around them in weeks 6 and 8. CONCLUSION: Fibrous membranous tissue formed around liquid nitrogen-treated bones may be vital for osteogenesis and revitalization of frozen bones.

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BACKGROUND: Masquelet membrane induction technology is one of the treatment strategies for large bone defect (LBD). However, the angiogenesis ability of induced membrane decreases with time and autologous bone grafting is associated with donor site morbidity. This study investigates if the PRP-FG-nHA/PA66 scaffold can be used as a spacer instead of PMMA to improve the angiogenesis ability of induced membrane and reduce the amount of autologous bone graft. METHODS: Platelet rich plasma (PRP) was prepared and PRP-FG-nHA/PA66 scaffold was synthesized and observed. The sustained release of VEGFA and porosity of the scaffold were analyzed. We established a femur LBD model in male SD rats. 55 rats were randomly divided into four groups depending on the spacer filled in the defect area. "Defect only" group (n = 10), "PMMA" group (n = 15), "PRP-nHA/PA66" group (n = 15) and "PRP-FG-nHA/PA66" group (n = 15 ). At 6 weeks, the spacers were removed and the defects were grafted. The induced membrane and bone were collected and stained. The bone formation was detected by micro-CT and the callus union was scored on a three point system. RESULTS: The PRP-FG-nHA/PA66 scaffold was porosity and could maintain a high concentration of VEGFA after 30 days of preparation. The induced membrane in PRP-FG-nHA/PA66 group was thinner than PMMA, but the vessel density was higher.The weight of autogenous bone grafted in PRP-FG-nHA/PA66 group was significantly smaller than that of PMMA group. In PRP-FG-nHA/PA66 group, the bone defect was morphologically repaired. CONCLUSION: The study showed that PRP-FG-nHA/PA66 scaffold can significantly reduce the amount of autologous bone graft, and can achieve similar bone defect repair effect as PMMA. Our findings provide some reference and theoretical support for the treatment of large segmental bone defects in humans.

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BACKGROUND: As a two-stage surgical procedure, Masquelet's technique has been used to care for critical-size bone defects (CSD). We aimed to determine the effects of modified and altered bone cement with biological or chemical enriching agents on the progression of Masquelet's induced membrane (IM) applied to a rat femur CSD model, and to compare the histopathological, biochemical, and immunohistochemical findings of these cements to enhance IM capacity. METHODS: Thirty-five male rats were included in five groups: plain polymethyl methacrylate (PMMA), estrogen-impregnated PMMA (E+PMMA), bone chip added PMMA (BC+PMMA), hydroxyapatite-coated PMMA (HA) and calcium phosphate cement (CPC). The levels of bone alkaline phosphatase (BALP), osteocalcin (OC), and tumor necrosis factor-alpha (TNF-α) were analyzed in intracardiac blood samples collected at the end of 4 weeks of the right femur CSD intervention. All IMs collected were fixed and prepared for histopathological scoring. The tissue levels of rat-specific Transforming Growth Factor-Beta (TGF-ß), Runt-related Transcription Factor 2 (Runx2), and Vascular Endothelial Growth Factor (VEGF) were analyzed immunohistochemically. RESULTS: Serum levels of BALP and OC were significantly higher in E+PMMA and BC+PMMA groups than those of other groups (P = 0.0061 and 0.0019, respectively). In contrast, TNF-α levels of all groups with alternative bone cement significantly decreased compared to bare PMMA (P = 0.0116). Histopathological scores of E+PMMA, BC+PMMA, and CPC groups were 6.86 ± 1.57, 4.71 ± 0.76, and 6.57 ± 1.51, respectively, which were considerably higher than those of PMMA and HA groups (3.14 ± 0.70 and 1.86 ± 0.69, respectively) (P < 0.0001). Significant increases in TGF-ß and VEGF expressions were observed in E+PMMA and CPC groups (P = 0.0001 and <0.0001, respectively) whereas Runx2 expression significantly increased only in the HA group compared to other groups (P < 0.0001). CONCLUSIONS: The modified PMMA with E and BC, and CPC as an alternative spacer resulted in a well-differentiated IM and increased IM progression by elevating BALP and OC levels in serum and by mediating expressions of TGF-ß and VEGF at the tissue level. Estrogen-supplemented cement spacer has yielded promising findings between modified and alternative bone cement.

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Critical bone loss after open fractures, while relatively uncommon, occurs most frequently in high-energy injuries. Fractures of the tibia account for the majority of open fractures with significant bone loss. A number of different surgical strategies exist for treatment of tibial bone loss, all with different advantages and disadvantages. Care should be taken by the surgeon to review appropriate indications and all relevant evidence before selecting a strategy.

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Introduction: Multi-trauma patients require a multidisciplinary team, especially in the presence of various body systems injuries. The evaluation focuses on the decision regarding the DCO and ETC approaches. Case presentation: A 24-year-old male patient with Glasgow Coma Score 8, arrived at the emergency room, followed by ATLS protocol. Orthopedic trauma included D8 vertebra unstable burst fracture, right open femur shaft fracture, left closed midshaft femur fracture, and right tibial plateau fracture of the knee. Case summary: A hemodynamically stable patient with bilateral femur fractures is directed toward the DCO approach. Discussion: An initial treatment for an external fixator across the knee on the right leg and a spine fusion and decompression of D5-10 surgery was made on the day of admission. Definitive fixation and conversion to internal fixators were done on day 9 after the accident. Postoperative drop-foot injury was seen in the right leg. A Masquelet technique was applied for the right femur segmental fracture due to gaps. Conclusion: DCO may be employed to temporarily stabilize fractures, allowing the patient to recover from other life-threatening injuries before definitive fixation. Further secondary procedures, such as the Masquelet technique, should be considered to optimize the results. Long-term follow-up and rehabilitation are part of recovery, aiming to optimize functional recovery and improve the patient's quality of life.

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Introduction: The masquelet technique is a two-stage procedure used by orthopedic surgeons to treat large segmental bone defects secondary to infection, trauma, and tumor resection. This technique characteristically requires the placement of a temporary cement spacer and subsequent bone grafting for complete reconstruction. We describe a unique case of segmental bone loss reconstruction in which a patient successfully achieved fracture union after the first step of the masquelet technique without bone grafting. Case Report: This is a case of a 21-year-old male who presented with an open femur fracture with 10 cm of segmental bone loss after a motorcycle collision. An antibiotic cement spacer was inserted according to the first stage of the masquelet technique. Due to considerable callus formation around the spacer, normal alignment, and pain-free ambulation at follow-up, further surgical intervention was not pursued, and the poly-methyl-methacrylate spacer was left in place. The fracture healed without infection, and the patient remained weight-bearing without pain. Conclusion: This case identifies a unique instance of successful fracture union of a 10 cm segmental bone defect despite the completion of only the first step in the masquelet procedure. While the masquelet technique is believed to be a mandatory two-step procedure, this unique case of rapid bone growth and fracture union warrants further research on the possibilities of masquelet-induced regeneration without bone grafting.

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BACKGROUND: Open tibial fractures often include severe bone loss and soft tissue defects and requires complex reconstructive operations. However, the optimal treatment is unclear. METHODS: This retrospective study enrolled patients with Gustilo type III open tibial fractures from January 2018 to January 2021 to assess the clinical utility of Masquelet technique together with microsurgical technique as a combined strategy for the treatment of open tibial fractures. The demographics and clinical outcomes including bone union time, infection, nonunion and other complications were recorded for analysis. The bone recovery quality was evaluated by the AOFAS Ankle-Hindfoot Scale score and the Paley criteria. RESULTS: We enrolled 10 patients, the mean age of the patients and length of bone defects were 31.7 years (range, 23-45 years) and 7.5 cm (range, 4.5-10 cm) respectively. Bone union was achieved for all patients, with an average healing time of 12.2 months (range, 11-16 months). Seven patients exhibited a bone healing time of less than 12 months, whereas 3 patients exhibited a bone healing time exceeding 12 months. No significant correlation was found between the length of bone loss and healing time. In addition, no deep infection or nonunion was observed, although 2 patients experienced wound fat liquefaction with exudates and 1 patient presented with a bloated skin flap. The average AOFAS Ankle-Hindfoot Scale score was 80.5 (range, 74-85), and all patients were evaluated as good or exellent based on the Paley criteria. CONCLUSIONS: Our study indicated that the use of the Masquelet technique and the microsurgical technique as a combined strategy is safe and effective for the treatment of Gustilo type III open tibial fractures.

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The Masquelet technique, also known as the induced membrane technique, is a surgical technique for repairing large bone defects based on the use of a membrane generated by a foreign body reaction for bone grafting. This technique is not only simple to perform, with few complications and quick recovery, but also has excellent clinical results. To better understand the mechanisms by which this technique promotes bone defect repair and the factors that require special attention in practice, we examined and summarized the relevant research advances in this technique by searching, reading, and analysing the literature. Literature show that the Masquelet technique may promote the repair of bone defects through the physical septum and molecular barrier, vascular network, enrichment of mesenchymal stem cells, and high expression of bone-related growth factors, and the repair process is affected by the properties of spacers, the timing of bone graft, mechanical environment, intramembrane filling materials, artificial membrane, and pharmaceutical/biological agents/physical stimulation.

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BACKGROUND: The treatment of bone and soft-tissue defects after open fractures remains challenging. This study aimed to evaluate the clinical efficacy of the Masquelet technique combined with the free-flap technique (MFFT) versus the Ilizarov bone transport technique (IBTT) for the treatment of severe composite tibial and soft-tissue defects. METHODS: We retrospectively analysed the data of 65 patients with tibial and soft-tissue defects and Gustilo type IIIB/C open fractures treated at our hospital between April 2015 and December 2021. The patients were divided into two groups based on the treatment method: group A (n = 35) was treated with the MFFT and internal fixation, and group B (n = 30) was treated with the IBTT. RESULTS: The mean follow-up period was 28 months (range 13-133 months). Complete union of both soft-tissue and bone defects was achieved in all cases. The mean bone-union times were 6 months (range 3-12 months) in group A and 11 months (range 6-23 month) in group B, with a significant difference between the two groups (Z = -4.11, P = 0.001). The mean hospital stay was 28 days (range 14-67 d) in group A which was significantly longer than the mean stay of 18 days (range 10-43 d) in group B (Z = -2.608, P = 0.009). There were no significant differences in the infection rate between group A (17.1 %) and group B (26.7%) (χ2 = 0.867, P = 0.352). The Total Physical Health Scores were 81.51 ± 6.86 (range 67-90) in group A and 75.83±16.14 (range 44-98) in group B, with no significant difference between the two groups (t = 1.894, P = 0.063). The Total Mental Health Scores were significantly higher in group A (90.49 ± 6.37; range 78-98) than in group B (84.70 ± 13.72; range 60-98) (t = 2.232, P = 0.029). CONCLUSION: Compared with IBTT, MFFT is a better choice of treatment for open tibial and soft-tissue defects with Gustilo IIIB/C fractures. IBTT is the preferred option when the tibial bone defect is large or if the surgeon's expertise in microsurgery is limited.

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BACKGROUND: There is no effective consensus on the choice of internal fixation method for the Masquelet technique in the treatment of large segmental bone defects of the distal tibia. Thus, the study aimed to investigate the outcomes of the Masquelet technique combined with double plate fixation in the treatment of large segmental bone defects. METHODS: This was a retrospective study involving 21 patients with large segmental bone defects of the distal tibia who were treated between June 2017 and June 2020. The length of bone defect ranged from 6.0 cm to 11 cm (mean, 8.19 cm). In the first stage of treatment, following complete debridement, a cement spacer was placed to induce membrane formation. In the second stage, double plate fixation and autologous cancellous bone grafting were employed for bone reconstruction. Each patient's full weight-bearing time, bone healing time, and Iowa ankle score were recorded, and the occurrence of any complications was noted. RESULTS: All patients were followed up for 16 to 26 months (mean, 19.48 months). The group mean full weight-bearing time and bone healing time after bone grafting were 2.41 (± 0.37) months and 6.29 (± 0.66) months, respectively. During the treatment, one patient had a wound infection on the medial side of the leg, so the medial plate was removed. The wound completely healed after debridement without any recurrence. After extraction of iliac bone for grafting, one patient had a severe iliac bone defect, which was managed by filling the gap with a cement spacer. Most patients reported mild pain in the left bone extraction area after surgery. The postoperative Iowa ankle score range was 84-94 (P < 0.05). In this cohort, 15 cases were rated as "excellent", and 6 cases as "good" on the Iowa ankle scoring system. CONCLUSION: The Masquelet technique combined with double plate fixation is a safe and effective method for the treatment of large segmental bone defects of the distal tibia.

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Segmental bone defects, often clinically treated with nondegradable poly(methylmethacrylate) (PMMA) in multistage surgeries, present a significant clinical challenge. Our study investigated the efficacy of 3D printed biodegradable polycaprolactone fumarate (PCLF)/PCL spacers in a one-stage surgical intervention for these defects, focusing on early bone regeneration influenced by spacer porosities. We compared nonporous PCLF/PCL and PMMA spacers, conventionally molded into cylinders, with porous PCLF/PCL spacers, 3D printed to structurally mimic segmental defects in rat femurs for a 4-week implantation study. Histological analysis, including tissue staining and immunohistochemistry with bone-specific antibodies, was conducted for histomorphometry evaluation. The PCLF/PCL spacers demonstrated compressive properties within 6 ± 0.5 MPa (strength) and 140 ± 15 MPa (modulus). Both porous PCLF/PCL and Nonporous PMMA formed collagen-rich membranes (PCLF/PCL: 92% ± 1.3%, PMMA: 86% ± 1.5%) similar to those induced in the Masquelet technique, indicating PCLF/PCL's potential for one-stage healing. Immunohistochemistry confirmed biomarkers for tissue regeneration, underscoring PCLF/PCL's regenerative capabilities. This research highlights PCLF/PCL scaffolds' ability to induce membrane formation in critical-sized segmental bone defects, supporting their use in one-stage surgery. Both solid and porous PCLF/PCL spacers showed adequate compressive properties, with the porous variants exhibiting BMP-2 expression and woven bone formation, akin to clinical standard PMMA. Notably, the early ossification of the membrane into the pores of porous scaffolds suggests potential for bone interlocking and regeneration, potentially eliminating the need for a second surgery required for PMMA spacers. The biocompatibility and biodegradability of PCLF/PCL make them promising alternatives for treating critical bone defects, especially in vulnerable patient groups.

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Critical-size bone defects up to 25 cm can be treated successfully using the induced membrane technique established by Masquelet. To shorten this procedure, human acellular dermis (HAD) has had success in replacing this membrane in rat models. The aim of this study was to compare bone healing for smaller and larger defects using an induced membrane and HAD in a rat model. Using our established femoral defect model in rats, the animals were placed into four groups and defects of 5 mm or 10 mm size were set, either filling them with autologous spongiosa and surrounding the defect with HAD or waiting for the induced membrane to form around a cement spacer and filling this cavity in a second operation with a cancellous bone graft. Healing was assessed eight weeks after the operation using µ-CT, histological staining, and an assessment of the progress of bone formation using an established bone healing score. The α-smooth muscle actin used as a signal of blood vessel formation was stained and counted. The 5 mm defects showed significantly better bone union and a higher bone healing score than the 10 mm defects. HAD being used for the smaller defects resulted in a significantly higher bone healing score even than for the induced membrane and significantly higher blood vessel formation, corroborating the good results achieved by using HAD in previous studies. In comparison, same-sized groups showed significant differences in bone healing as well as blood vessel formation, suggesting that 5 mm defects are large enough to show different results in healing depending on treatment; therefore, 5 mm is a viable size for further studies on bone healing.

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Case: A 30-year-old male was admitted in our hospital having an open left distal femoral fracture with 9-cm segmental bone defect and a closed proximal left tibial fracture. He was treated successfully using a Hybrid (Titanium Cage and Bone Graft) Masquelet Induction Membrane Technique (MIMT). His femoral fracture united 3-months post - operatively. The left tibia was treated initially with two locking plates. Following infection, a 3-cm tibial bone gap was treated with external fixation and conventional MIMT. The tibial fracture united 12-months post- operatively. Conclusion: The Hybrid MIMT achieved a successful healing outcome in this challenging case.

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OBJECTIVES: Septic arthritis and osteomyelitis are serious infections. Several treatment methods for the small joints and bones of the hands have been reported. We hypothesized that antibiotic-impregnated cement spacers could be useful for purulent finger osteomyelitis with bone and joint destruction. PATIENTS AND METHODS: Seven patients with finger osteomyelitis with bone and joint destruction were treated using vancomycin (VCM)-impregnated cement spacers. During the first surgery, a cement spacer was placed in the space created after debridement, maintaining finger length. Intraoperative specimens were tested for bacterial growth. Systemic antibiotic treatment was administered. A second surgery was performed 6-8 weeks after the first. After spacer removal, reconstruction surgeries were performed: arthrodesis using the Masquelet technique (n = 5), vascularized bone grafting (n = 1), and silicone implant arthroplasty (n = 1). We assessed the pathogenic bacteria, duration of antibiotic treatment, infection control, time to bone union, pain on visual analogue scale (VAS) (0 - 100), total active motion (TAM) of the affected fingers, and grip strength. RESULTS: The pathogenic bacteria were methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, and unknown in 3, 3, and 1 patients, respectively. Mean duration of antibiotic treatment was 6.4 weeks. In all patients, infection resolved without recurrence. One patient underwent joint arthroplasty; otherwise, bone union was achieved in 6 patients. Mean VAS score for pain was 0.9. Mean TAM was 147° for the index and middle fingers and 50° for the thumb. Mean grip strength was 86.4% of that of the unaffected side. CONCLUSION: VCM-impregnated cement spacers could be useful for finger osteomyelitis, facilitating effective infection control and the maintenance of finger length, even in severe conditions.

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