Lodewijks Anna, Blokhuis Taco, van Griensven Martijn, Poeze Martijn
Department of Traumatology, Maastricht UMC+ (University Medical Center), Maastricht, NLD.
Institute of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, NLD.
Cureus. 2024 Aug 6;16(8):e66256. doi: 10.7759/cureus.66256. eCollection 2024 Aug.
The need for an artificial scaffold in very large bone defects is clear, not only to limit the risk of graft harvesting but also to improve clinical success. The use of custom osteoconductive scaffolds made from biodegradable polyester and ceramics can be a valuable patient-friendly option, especially in case of a concomitant infection. Multiple types of scaffolds for the Masquelet procedure (MP) are available. However, these frequently demonstrate central graft involution when defects exceed a certain size and the complication rates remain high. This paper describes three infected tibial defect nonunions with a segmental defect over 10 centimeters long treated with a three-dimensional (3D)-printed polycaprolactone-tricalcium phosphate (PCL-TCP) cage in combination with biological adjuncts. Three male patients, between the ages of 37 and 47, were treated for an infected tibial defect nonunion after sustaining Gustilo grade 3 open fractures. All had a segmental midshaft bone defect of more than 10 centimeters (range 11-15cm). First-stage MPs consisted of extensive debridement, external fixation, and placement of anterior lateral thigh flaps. Positive cultures were obtained from all patients during this first stage, which were treated with specific systemic antibiotics for 12 weeks. The second-stage MP was carried out at least two months after the first stage. CT scans were obtained after the first stage to manufacture defect-specific cages. In the final procedure, a custom 3D-printed PCL-TCP cage (Osteopore, Singapore) was placed in the defect in combination with biological adjuncts (BMAC, RIA-derived autograft, iFactor, and BioActive Glass). Bridging of the defect, assessed at six months by CT, was achieved in all cases. SPECT scans six months post-operatively demonstrated active bone regeneration, also involving the central part of the scaffold. All three patients regained function and reported less pain with full weight bearing. This case report shows that 3D-printed PCL-TCP cages in combination with biological adjuncts are a novel addition to the surgical treatment of very large bone defects in (infected) post-traumatic nonunion of the tibia. This combination could overcome some of the current drawbacks in this challenging indication.
对于非常大的骨缺损而言，人工支架的必要性显而易见，这不仅是为了降低取骨移植的风险，也是为了提高临床成功率。使用由可生物降解聚酯和陶瓷制成的定制骨传导支架可能是一种对患者有益的选择，尤其是在伴有感染的情况下。有多种用于Masquelet技术（MP）的支架。然而，当骨缺损超过一定大小时，这些支架常常会出现中央移植物萎缩，且并发症发生率仍然很高。本文描述了三例感染性胫骨缺损不愈合病例，其节段性缺损超过10厘米，采用三维（3D）打印的聚己内酯-磷酸三钙（PCL-TCP）骨笼结合生物辅助材料进行治疗。三名年龄在37至47岁之间的男性患者，在遭受Gustilo 3级开放性骨折后，因感染性胫骨缺损不愈合接受治疗。所有患者均有超过10厘米（范围为11 - 15厘米）的节段性骨干中部骨缺损。第一阶段的MP包括广泛清创、外固定以及股前外侧皮瓣移植。在第一阶段，所有患者的培养结果均呈阳性，针对这些感染使用特定的全身性抗生素治疗12周。第二阶段的MP在第一阶段至少两个月后进行。在第一阶段后进行CT扫描以制作针对缺损的骨笼。在最终手术中，将定制的3D打印PCL-TCP骨笼（Osteopore，新加坡）与生物辅助材料（骨髓抽吸浓缩物、逆行交锁髓内钉抽取的自体骨、iFactor和生物活性玻璃）一起放置在缺损处。通过CT在六个月时评估，所有病例的骨缺损均实现了桥接。术后六个月的SPECT扫描显示有活跃的骨再生，且再生也涉及骨笼的中央部分。所有三名患者均恢复了功能，并且报告在完全负重时疼痛减轻。本病例报告表明，3D打印的PCL-TCP骨笼结合生物辅助材料是胫骨创伤后感染性不愈合中非常大的骨缺损手术治疗的一种新方法。这种组合可以克服这一具有挑战性适应症中当前存在的一些缺点。
