Ilizarov Methods versus Masquelet’s Technique in Management of Segmental Skeletal Defects of the Femur

Ilizarov Methods versus Masquelet’s Technique in
Management of Segmental Skeletal Defects of the Femur
PhD Thesis protocol submitted for partial fulfillment of PhD Degree in orthopedic surgery
By
Abdallah Ibrahim Jomaa El Azanki
MBBCh
Faculty of Medicine -- Kursk State Medical University
MSc
Faculty of Medicine -- Mansoura University
2020

Supervisors
Prof. Brakat Sayed Elalfy
Professor of orthopedic surgery
Faculty of Medicine - Mansoura University
Prof. Nabil Ahmed Elmoghazy
Professor of orthopedic surgery
Dr. Sallam Ibrahim Fawzy
Assistant Professor of orthopedic surgery
( Principal Supervisor)

Reconstruction of long tubular bone defects is always one of the most difficult
problems in orthopaedic surgery
Segmental Skeletal Defects (SSD) may result from
 High-energy trauma
 Debridement of osteomyelitis
 Tumor resection
 Congenital anomalies
Some defects are accompanied by major soft tissue injuries that limit the
functional outcome (independent of the actual bone loss )
(Mauffrey et al., 2015; Paley and Maar, 2000)
SSD Causes

Free bone graft was the hallmark in management of segmental skeletal defects.
 high failure rate  rejection or sequestration  result of purulent infection
Amount of autograft available for filing big SSD is limited.
Reconstruction of large SSD with vascularized bone graft.
 Useful in the upper limb
 Lower limb :  fibula or iliac crest
• takes years to hypertrophy
• fracture once or more before remodeling.
 Microvascular bone graft often fails to unite to the recipient bone at one or both ends
(Green, 1994;Ilizarov and Ledyaev, 1992; Pederson and Person, 2007)
Grafting Hx

All these treatment protocols have variable rates of success
or failure and are limited in their ability to reestablish extremity
length and correct the deformity.
 It is common to have :
• Persistent infection
• Soft-tissue contracture
• Prolonged fracture disease
• Residual deformity
• Eventual amputation
(Cattaneo et al., 1992; Lowenberg and Githens, 2015)

In 1956 Ilizarov has developed the technique of distraction osteogenesis.
Stimulus of pure distraction applied to a special cortecotomy site to induce new
bone formation at the distraction gap.
Corticotomy is made through a healthy bone segment at some distance from the
defect site.
 Components of the frame are attached with wires and half pins to the segment of
bone between the corticotomy and the defect.
Steady traction is applied to the intercalary bone segment to elongate the
corticotomy region while closing the original skeletal defect in the same time.
Ilizarov
(Ilizarov, 1989; Murray and Fitch, 1996)

 In Ilizarov Methods:
 Limb length is maintained
 Deformity is corrected
 Limb shortening is gradually overcome
 SSD are eliminated
 Reported variable Tx results:
• Good results
• High complication rate
(ChADDhA et al., 2010; Cierny and Zorn, 1994; Dahl et al., 1994; Lowenberg and Githens, 2015)
Pros & Cons

 In the early 21th century a two-stage technique for reconstruction of SSD was
described.
 First stage a cement spacer fills the defect.
 This induces the formation of specialized tissue or membrane around it.
 During the second stage the cement spacer is removed, and bone graft is
placed within he induced membrane.
Masquelet
(Masquelet et al., 2000; Masquelet and Begue, 2010; Pelissier et al., 2002)

 This membrane was found to be:
 Impermeable
 hypervascular
 biologically active, it secretes GF :
• Vascular endothelial growth factor and transforming growth factor-beta-1 (VEGF, TGF-_1)
• Osteoinductive factors as bone morphogenetic protein-2 (BMP- 2).
 Such options prevents bone resorption and favors growth and maturation
of the bone graft
This is called Masquelet’s Technique, which is being widely used with
many promising results
Masquelet
(Chotel et al., 2012; Karger et al., 2012)

The aim of the present study is to compare the results of Ilizarov
methods versus Masquelet’s technique in management of
segmental skeletal defects (SSD) of the Femur.

Objectives
1. Reporting bone healing results in both techniques
2. Functional results while and after treatment.
3. Studying different factors such as body mass index (BMI), blood glucose level, life habits
recording and correlating it to clinical outcomes.
4. Attentive watching for transport time in accordance to the intraoperative SSD measure.
5. Patient’s satisfaction with the management
6. Different SSD correlations ( CT, Clinical, Long Film )

Type of the study:
Retrospective and prospective randomized comparative study (Panel Study)
Study locality:
Department of orthopedic surgery, Mansoura university and emergency hospitals.
Time:
During the period of April 2018- 2022 .

Patients:
Study will include patients with SSD of 4 cm or more:
Exclusion criteria:
 Skeletally immature patients
 SSD less than 4 cm
 Patients with Osteomyelitis
 Patients treated with:
 Regular External Fixator
 Oncological etiology Cases- post
resection SSD
Inclusion criteria:
 Adult patients with SSD
 Post traumatic bone loss
 Post traumatic Non-union
 Post traumatic Malunion
 Post traumatic Infection sequalae

 Patients to be included are those with post-traumatic SSD that present to Mansoura
University Emergency Hospital and “Limb Lengthening & Deformity Correction”
Out-patient Clinic at the department of orthopedic surgery, Mansoura university.
 Patients will be examined clinically and radiologically
 SSD will be measured twice : Preop. By CT scanogram and intraoperatively
 Treatment option will be in accordance to patient’s randomization number and he/she will be
consented after surgical plan/approach explanation.

 Clinical Examination :
• Pain
• Neuro-vascular status of the limb.
• Soft tissue condition (Gustilo classification)
• Deformity in the lower limb.
• Vital signs (Pulse, Blood pressure, Respiratory rate)
Preoperative Evaluation
 Patient History :
• Age, Sex, Occupation, Residency
• Medical History (diseases or previous trauma)
• Medications (immunosuppressive drugs, steroids, or osteoporosis Tx)
• Nutritional status
• Alcoholism / Smoking / Addiction

 Radiological investigations:
• Plain radiographs:
 Antero-posterior, Lateral view of the Femur
• Computed Tomography:
 CT scan with the four views (axial, coronal, sagittal and 3D) will be
ordered to better understand the osseous pattern.
 CT Scanogram will be done to measure the SSD.
 Laboratory investigations:
• CBC
• INR / PTT
• ABG if resuscitated
• HbA1C

Intraoperative and Postoperative Methods
• After debridement SSD will be measured
• SSD measured by CT scan will be compared to the intraoperative measure.
• In case of post traumatic infection sequalae , deep tissues for culture and
cytology will taken.
• Patients will know the estimated time needed for bone transport / second
stage timing and requirements for each method

 In Masquelet’s technique patients, second stage will happen after 4-8 weeks in
ordinance with clinical, laboratory and radiological status.
 Autograft will be harvested from the iliac bone minced around the fibular strut.
In Ilizarov method patients, distraction osteogenesis process will start according to age
and or bone and health quality (7-14 days).
 Graft at the docking site will be done when needed.
 Postoperative methods:

 Patients will be followed up at the “Limb Lengthening and Deformity
Correction” OPC with interval of 2,4,8 weeks
 Later, FU every 3 weeks till docking site flags or the same for Masquelet’s 2nd
stage patients.
 Follow up AP and Lateral View X-rays will be done:
• Regenerate and healing status
• Confirm union/ consolidation
 Long film standing lower limb x-ray anteroposterior and lateral views will be
used in both methods to study the mechanical axis of the limb and final LLD.
Postoperative methods:

 Complications to be reported:
 Mal-union
 Non-union
 Infection (superficial or deep)
 Neurovascular status
 Failure of fixation or transport
 Soft tissue problems will noted and managed accordingly even
by flaps or by histogenesis.

 Ethical consideration:
1. Study protocol will be submitted for approval by IRB.
2. Approval of mangers of hospital in which the study will be conducted.
3. Informed written consent will be obtained from each participant sharing the study.
4. Confidentiality and personal privacy will be respected in all the levels of the
study. Collected data will not be used for any other purpose.

Statistical analysis:
The collected data will be coded, processed and analyzed using SPSS
program (version17) for windows. The appropriate statistical tests will be used
when needed. P values less than 0.05 (5%) will be considered to be statistical
significant.

Ilizarov Methods versus Masquelet’s Technique in Management of Segmental Skeletal Defects of the Femur

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