Case report
Reconstruction of an extensive soft tissue and bone defect of the first metatarsal with the use of Masquelet technique: A case report

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Abstract

The literature regarding reconstruction of foot bone defects is limited. The purpose of this study is to present a case report with an extensive bone defect of the first metatarsal bone which was treated with the use of the induced membrane technique.

A 53-year-old man, with comminuted foot grade IIIb open fracture was treated with the Masquelet procedure. At 14 months follow-up, clinical and radiological assessment of the foot revealed osseous healing and no signs of infection, osteolysis or hardware failure. At 18 months follow-up, the patient had no pain and returned to his usual daily activities. The Masquelet procedure provides an effective method of treatment of extensive bone defects of the foot. It can restore the normal length and metatarsal arch minimizing the risk of complications that occurs with other surgical procedures.

Level of evidence

Level V, case report.

Introduction

Reconstruction of lower extremity diaphyseal bone defects is demanding and requires a combination of orthopedic and plastic surgery techniques. Defects less than 2 cm and up to 4 cm can be treated with autogenous bone grafting [1]. The vascularized fibula autograft and the Ilizarov bone transfer techniques are commonly used to restore defects greater than 5 cm, but they are associated with several disadvantages. When the distraction osteogenesis method is used, complications such as pin-tract infection, mal-union, non-union and problems with the docking-site have been reported, while the need for long-term application of the external fixator creates difficulties in patients’ compliance to the treatment [2]. With the free fibula transfer, there is a significant risk of donor site pain and morbidity, whilst prolonged operative time and microsurgery expertise are required [3]. Masquelet first described the induced membrane technique for the reconstruction of extensive diaphyseal bone loss up to 25 cm in length [4]. This is a two-staged approach and the first procedure involves radical soft tissue and bone debridement. A cement spacer is implanted at the site of the bone defect preventing fibrous tissue invasion and inducing the formation of a biological pseudo-membrane that will revascularize the bone graft. At the second stage, 6–8 weeks later, the cement spacer is carefully removed and the defect is filled with morcelized cancellous autologous bone graft, while the bone fragments are usually stabilized with plating or nailing. Numerous human [5], [6], [7], [8], [9], [2], [10], [11], [12], [13], [14], [15] and animal [16], [17], [18] studies have been reported regarding the use of Masquelet technique. However, the literature regarding reconstruction of foot bone defects is limited. The purpose of this study is to present a case report with an extensive bone defect of the first metatarsal bone which was treated with the use of the induced membrane technique. The staged method is described succinctly and useful tips are being discussed for the reconstruction of the medial arch of the foot.

Section snippets

Case report

A 53-year-old man, with comminuted left distal tibia and ipsilateral foot grade IIIb open fractures, was referred to our institution. The patient was a motor-bike driver and he injured his left ankle 3 weeks before admission to our clinic after a road traffic accident. The initial injuries were multiple involving brain and right brachial plexus contusion, and right pleural effusion. Following careful evaluation with ATLS protocol, wound debridement was made and an external fixator was applied

Discussion

Techniques for reconstructing extensive bone defects have evolved in an attempt to restore the length of diaphyseal bones and function of adjacent joints [19], [20], [21]. The free vascularized fibular autograft and distraction osteogenesis still remain the most common bone defect reconstruction methods. Despite their reported advantages (biological reconstruction and ability to restore the required bone length), they have been associated with several drawbacks. Donor site morbidity, technical

Conclusion

Reconstruction of soft tissue and bone defects is quite difficult and different techniques have been used to manage high-energy injuries of the foot. The Masquelet procedure provides an effective method of treatment of such extensive bone defects. It can restore the normal length and metatarsal arch minimizing the risk of complications that occurs with other surgical procedures.

Further studies are desirable to expand its use in the reconstruction of bone defects of the foot and verify the

Conflict of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Acknowledgements

All authors were fully involved in the study and preparation of the manuscript and that the material within has not been and will not be submitted for publication elsewhere.

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