Morelli Ilaria, Drago Lorenzo, George David A, Gallazzi Enrico, Scarponi Sara, Romanò Carlo L
Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy.
Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy.
Injury. 2016 Dec;47 Suppl 6:S68-S76. doi: 10.1016/S0020-1383(16)30842-7.
The induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union.
A systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords "Masquelet technique" and "induced membrane technique". Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients' clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data.
Seventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001).
IMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis.
Further studies are needed to demonstrate the role the patients' clinical features and IMT variants have upon achieving bone union and infection eradication.
诱导膜技术（IMT）或马斯克莱技术是一种用于治疗骨不连和骨缺损的两阶段外科手术。许多作者对该技术进行了改进。本研究旨在比较诱导膜技术的手术改进方法，并评估其在根除感染和实现骨愈合方面的疗效。
按照PRISMA指南进行系统评价。使用关键词“马斯克莱技术”和“诱导膜技术”检索PubMed和其他医学数据库。纳入的文章需为英文、法文或意大利文撰写，涉及用于成人长骨的诱导膜技术，报告至少5例且平均随访12个月。检索患者的临床特征、骨缺损特征、病因、手术数据、并发症、再次干预、愈合率和感染根除率。采用费舍尔精确检验、卡方检验和非配对t检验对个体患者数据进行统计分析。
17篇论文符合纳入标准（427例患者）。其中，只有10项研究报告了个体患者数据（137例）。愈合率为89.7%，91.1%的病例感染得到纠正。骨缺损长度为0.6至26厘米。主要并发症为表浅（21例；4.9%）和深部手术部位感染（19例；4.4%）、诱导膜技术步骤之一失败（感染持续或骨不连，77例，18%），随后需要进一步手术。手术改进方法包括使用抗生素涂层间隔物、第一步手术时进行内固定、使用扩髓-冲洗-吸引技术、髂嵴植骨、骨替代物和生长因子。然而，单因素分析仅显示再次干预需求与较差的骨愈合率（p = 0.005）和并发症（p <0.001）呈正相关，而因骨感染接受诱导膜技术治疗的患者手术并发症风险更高（p <0.001）。
诱导膜技术旨在实现骨愈合和根除感染，但18%的病例出现感染持续或骨不连，需要再次干预。这可能与该技术应用的不同解剖部位以及不同的局部和患者相关情况有关。我们认为，实现骨愈合的手术技术选择应根据个体患者的需求进行调整。本系统评价受到符合我们纳入标准的研究较少以及数据报告高度变异性的限制，无法进行荟萃分析。
需要进一步研究以证明患者的临床特征和诱导膜技术改进方法在实现骨愈合和根除感染方面的作用。
