Reconstruction of massive bone loss with the combination between Masquelet technique, and
distraction osteogenesis method by using a locally modified AO tubular device, guided with an
interlocking nail for reconstructing bone loss 20 cm due to a malignant bone tumor in the femur
(case report)

Orthopedic Surgery Department, Oncology Department, Tichreen Military Hospital, Dmascus ,Syria
By: Dr.Imad Al Hariri, head of the orthopedic surgery department at Tichreen Hospital
Dr.Jihad Mando ,head of the Oncology department, at Tichreen Hospital
.Tel: 00963-938550183-Email: imadhariri65@gmail.com
Keys words: (external fixation, . Masquelet technique, distraction osteogenesis, reconstruction bone, osteosarcoma ),

Abstract

The massive bone loss after treatment surgical of the bone tumor pose big challenge to the orthopedists, this were depending on the site of the tumor in the bone. We were successfully treated bone loss in the femurs of a young man have about 20 cm of bone loss caused by wide resection of osteosarcoma in the femur. We had used three techniques :. Masquelet method and progressive induction method using external fixator(monolateral) and retrograde femoral nail. By two surgical stages. 6 months interval and follow up 15 months to achieve bone consolidation. And we findthis is the first case in the literatures were utilized for it this combination in the
treatment.
• Masquelet’s induced membrane technique (MIMT) is a relatively new, two-stage surgical procedure to reconstruct segmental bone defects, First performed by Dr. Masquelet in the mid-1980s, MIMT has shown great promise to revolutionize critical-sized bone defect repair and has several advantages over its alternative, distraction osteogenesis (DO). Also, its success in extremely challenging cases (defects > 15 cm). The delay of the second stage of this method for more than six months keeper the induced membrane preserving its biological properties
• External fixation has been widely used for the treatment of limb length discrepancy, deformity correction, and bone defect using
distraction osteogenesis. We can use this technique for the treatment of reconstruction after malignant bone tumor resection. The advantages of external fixation for the treatment include a possibility of reconstructing the bone loss more than 6 cm.
• The used of interlocking nail with the combination of the external fixation can guide the bone segment pendent the transporting of the bone, becoming a widely used technique for the treatment of the bone deficiency by using distraction osteogenesis.
• We have used these techniques to reconstruct about 20 cm of bone loss caused by wide resection of osteosarcoma in the femur. Masquelet method and progressive induction method using external fixator and retrograde femoral nail. And this is making our case the first case in the literatures were utilized for it this combination in the treatment.
• The Ao external fixation is designs to fix the bone segments in open fractures. In this case, we used an external AO tubular fixation device by adding a piece to transform the bone. It achieved a transformation of about 17.5 cm of bone. This is difficult to achieve with any other external fixing device.

methods:

• A 23-year-old man, admitted to the hospital with a diagnosis: High grade fibroblasts osteosarcoma in his right femur at the junction of middle and third parts, a distance of the tumor is 14 cm in the femoral diaphysis, proximally to the line of the knee joint is about 7 cm.
Treated surgically in two stages. The first stage: wide resection of the tumor (about 20 cm of bone with a safety margin of bone and surrounding soft tissues). With temporary reconstruction by cement (Masquelet’s) and fixing the femur by a retrograde inter-medullary nail from the knee joint. And after 6 months we have been elevated the cement from the femur and we are using an external AO tubular fixation mono-lateral to transfer the bone from subtrochanteric area to the distal part with guiding by inter-medullary nail. Lengthening was monitored for a period of about 15 months.

Results:

The bone was transferred about 17.5 cm. And finally, we were continuing the treatment by filling an iliac graft to continuing treating the rest bone loss 2.5 cm and then fixed with a anatomic plate, the tumor was recovered without any localized relapse or metastasis. After 15 months of monitoring the consolidations was achieved in the femur. The hole massive losing bone was fully consolidated and the patient restoring their activities without metastases and local recurrence of the tumor site.

Conclusion:

• These three combination techniques have very useful procedures in reconstruction large bone defect in the treatment of different cases in orthopedic and traumatic surgeries. And the bone which was induced by this technic is natural and has the main properties of the original bone. And has less complications comparing with the others reconstructions technics like allografts, allograft prosthetic composites, recycled autograft, and modular or custom-made endoprostheses. This will be added another useful technique and less costing for reconstructions massive bone losing in the lower or upper extremities