Intramedullary Nails Yield Superior Results Compared with Plate Fixation When Using the Masquelet Technique in the Femur and Tibia

Abstract

Objectives:To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique.Design:Retrospective cohort study.Setting:Four Level 1 Academic Trauma Centers.Patients/Participants:All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018.Intervention:Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks.Main Outcome Measurements:Time to union, number/reason for reoperations, time to full weight-bearing, and any complications.Results:One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN."Conclusions:This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.