Unique Case of Accelerated Bone Growth Precipitating a One-Stage Masquelet: A Report

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. Megan Tersteeg et al 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.

A 21-year-old male with a history of mild scoliosis, no previous fractures, and daily smoking for 2 years sustained multiple musculoskeletal injuries after a motorcycle collision. The injuries included a closed left femoral shaft injury and an open right Gutstilo and Anderson Type III A femur fracture with 10 cm of segmental bone loss. On the night of the injury, the patient underwent emergent irrigation, debridement, and temporary stabilization of his fracture with external fixation. Tobramycin antibiotic cement with vancomycin powder was placed within the thigh wound with a negative-pressure wound vacuum to cover the wound. 2 days later, once resuscitated, the right femur underwent another irrigation and debridement with an antibiotic bead and wound vacuum exchange. After multiple irrigation and debridement procedures of the lower extremity, the wound bed was amenable to definitive fixation of the femur.

On day 5, the femur underwent intramedullary retrograde nailing with the placement of two proximal and two distal interlocking screws, revealing a 10-cm segmental bone defect. The defect was filled with tobramycin antibiotic cement mixed with vancomycin powder and underwent delayed primary wound closure. This was the first stage of a proposed masquelet technique treatment plan for this injury. He was made non-weight-bearing in his right lower extremity due to additional ipsilateral musculoskeletal injuries, but the patient was encouraged to range the knee from 0° extension to 140° flexion as often as possible. The remainder of his musculoskeletal injuries eventually underwent definitive fixation, with subsequent discharge to a rehabilitation center on hospital day 13.

The patient was seen in clinic 1 month after his initial injury, at which time he was non-weight-bearing in his right lower extremity and receiving outpatient physical therapy. His X-rays demonstrated unchanged osseous alignment with early callus formation. He was made to be a weight bearing as tolerated and continued his home exercise program to improve his knee and ankle range of motion (ROM) until his subsequent follow-up. At the 8-week follow-up visit, the patient’s pain was well controlled, and he was weight-bearing as tolerated on the right lower extremity up to his full bodyweight of 65.8 kg. There were no signs of infection, and his X-rays at the time showed abundant callus formation bridging the fracture site around the cement spacer. At this time, the second stage of the masquelet technique with bone grafting was considered.

However, due to significant callus formation and minimal pain with ambulation, the decision was made to continue to monitor his progress and reevaluate at his next visit. Six-month post-injury, he was weight-bearing without assistive devices, without any gait abnormalities, and with no pain. Radiographs revealed the interval progression of callus formation. At the last follow-up, 1 year after definitive fixation, the patient reported no complaints regarding his right lower extremity. He had full ROM of knees, a normal, non antalgic gait, and had fully returned to work in construction. Radiographs demonstrated bridging callus formation in three out of four cortices and unchanged alignment.

The patient concluded that - “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. This warrants further research on the mechanisms behind masquelet-induced regeneration without bone grafting and consideration of circumstances in which fracture union can be obtained following stage one of the masquelet procedures.”

Further reading:

Unique Case of Accelerated Bone Growth Precipitating a One-Stage Masquelet: A Case Report Megan Tersteeg et al Journal of Orthopaedic Case Reports 2024 May:14(5):Page 94-98