Masquelet Technique for Phalangeal Reconstruction and Osteomyelitis Manuscript
Osteomyelitis of the finger presents a challenging problem. Although there are multiple treatments described in the literature, the infection often results in eventual amputation. We present a case of an open fracture of the index finger complicated by non-union, infection, and osteomyelitis. This was successfully treated by the placement of an antibiotic cement spacer and subsequent reconstruction with iliac crest bone graft, following the two-stage Masquelet technique, using intravenous and oral antibiotics. We show that this technique, although infrequently described in the hand and fingers, can be a successful option for the treatment of phalangeal osteomyelitis and phalangeal reconstruction.
Osteomyelitis of the phalanges requires thorough treatment due to the high risk to finger function and amputation.1,2 In one study of patients with metacarpal and phalangeal osteomyelitis, there was an overall incidence of amputation of 39%, and those with a history of trauma and wound contamination, the wound had a 54% chance of undergoing amputation. Another series indicated that a history of diabetes was associated with a higher amputation rate of 63%.3
We describe a case in which the Masquelet technique was used for non-union of an open index finger proximal phalanx fracture complicated by osteomyelitis of both the proximal and middle phalanges. The patient was informed that details of his case would be submitted for publication and provided written consent.
A 50-year-old, right-hand-dominant, male, state trooper presented with a right index finger injury from being caught in the spinning wheel of a car. The injury had been treated at another institution with debridement and placement of an external fixator spanning the proximal and middle phalanges. On initial presentation, eleven days after his primary surgery, the external fixator was in place with a healing laceration over almost the entire length of the finger on the radial side and a puncture wound on ulnar side. Radiographs showed a comminuted displaced fracture of the shaft and distal articular surface of the proximal phalanx of the index finger (Figure 1). The patient’s history included poorly controlled insulin-dependent Type II diabetes with previous episodes of diabetic ketoacidosis and hemoglobin AlC of greater than 14.
Without signs of bony union at two months after his initial presentation, he was taken back to the operating room for external fixator modification and bony debridement (Figure 2). Pathologic analysis showed acute osteomyelitis although cultures were negative. Intravenous Cefadroxil was initiated for a six-week course, followed by Cephalexin.
There continued to be an absence of bony healing on radiographs. The patient strongly preferred to avoid amputation. After giving informed consent he elected to attempt the Masquelet technique in this unique setting. First, the external fixator was removed and the previous incision was opened over the middle phalanx and proximal phalanx. The infected bone of the proximal and middle phalanges was excised. An external fixator was reapplied outside the zone of debridement. Bone cement was prepared with a mixture of 2g of tobramycin and 4g of vancomycin. The cement was cylindrically shaped around a premeasured 0.045 K-wire and inserted into small drill holes in the medullary canals of the proximal and middle phalanges, recreating the appropriate length. The external fixator pins were then reconnected with a bar to maintain the proper alignment and length (Figure 3). Pathologic analysis demonstrated osteomyelitis. Cultures taken at this time grew staphylococcus haemolyticus, and he was placed on Augmentin 875mg twice daily.
Six weeks later, the bioactive membrane was incised and the cement spacer removed. There was no gross evidence of infection. The area was measured and an appropriately sized portion of the iliac crest was harvested to fill the void. The 65mm bone graft was shaped with additional dowels at each end, and press-fit into the middle and proximal phalanges. The 40-degree flexion contracture at the distal interphalangeal joint was released and reduced to 20°. A 0.062 K-wire was passed retrograde from the tip of the finger through the phalanges and graft into the head of the metacarpal. Oblique 0.045 K-wires were placed from the radial side of the middle and proximal phalanges into the graft to add additional stability. The wires were cut and buried under the skin. The middle phalanx angulation was accepted in order to accomplish the in-line pinning of all bony segments (Figure 4). Osteomyelitis was absent from pathologic analysis. Cultures yielded no growth, but he was continued on Levaquin 500 mg daily for a total of eight weeks. Use of an external bone stimulator began.
After radiographic evidence of integration of the bone graft, five months later the three pins were removed (Figure 5). Intraoperative pathology and cultures were negative. At his most recent follow up, fourteen months after the second stage of the Masquelet technique, he appeared free of infection. His index finger metacarpophalangeal joint motion was 0-35 degrees, without interphalangeal joint motion. He reported being satisfied with his finger function and was able to return to work as a state trooper (Figure 6). QuickDASH score was 0 at fourteen months after the first operation.
There are few descriptions using the Masquelet two-stage technique in the hand. An alternative method of reconstruction of metacarpals is the two-stage Masquelet technique.4,5 This technique was first described for long-bone defects in the leg, and was found to be successful in both aseptic and septic conditions. 6,7
These injuries often require both complex bony and soft tissue reconstruction.8,9 Moris et al reported a series of 18 patients with open complex fractures of the phalanx or metacarpal treated by cement spacers without antibiotics, and showed that the two-stage technique can be used for traumatic bone with soft tissue loss.8 Lum et al also described a case report of first metacarpal reconstruction after close-range shotgun injury.9 Tabib described successful use of the technique for second metacarpal chronic osteomyelitis due to pin infection.10
Our patient’s infected non-union of his phalangeal fracture and uncontrolled diabetes made amputation seem inevitable. By following the Masquelet two-stage technique, we salvaged the use of the patient’s index finger with bony reconstruction and eradication of infection. When planning to use the technique, potential considerations include the extent of the injury, the need for soft tissue coverage, appropriate bone graft, cement use, antibiotic treatment, and timing regarding the staged surgeries. Our case study shows that the Masquelet two-stage technique is a versatile tool that can also be applied in the treatment of non-union complicated by osteomyelitis of the phalanges.
- Pinder R, Barlow G. Osteomyelitis of the hand. J Hand Surg Eur Vol. 2016 May; 41(4): 431-40.
- Honda H, McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg. 2009 May; 34(6): 1135-6.
- Francel TJ, Marshall KA, Savage RC. Hand infections in the diabetic and the diabetic renal transplant recipient. Ann Plast Surg. 1990 Apr; 24(4): 304-9.
- Zappaterra T, Ghislandi X, Adam A, Huard S, Gindraux F, Gallinet D, Lepage D, Garbuio P, Tropet Y, Obert L. [Induced membrane technique for the reconstruction of bone defects in the upper limb. A prospective single center study of nine center study of nine cases]. Chir Main. 2011 Sept; 30(4): 255-63.
- Micev AJ, Kalainov DM, Soneru AP. Masquelet technique for treatment of segmental bone loss in the upper extremity. J Hand Surg Am. 2015 Mar; 40(3): 593-8.
- Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am. 2010 Jan; 41(1): 27-37.
- Taylor BC, French BG, Fowler TT, Russell J, Poka A. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg. 2012 Mar; 20(3): 142-50.
- Moris V., Loisel F., Cheval D., et al: Functional and radiographic evaluation of the treatment of traumatic bone loss of the hand using the Masquelet technique. Hand Surg Rehabil 2016; 35: pp. 114-121.
- Lum ZC, Park L, Huff KE, Ibrahim MA. The masquelet technique for thumb metacarpal reconstruction following trauma. JBJS Case Connect. 2018 Jan-Mar; 8(1): e19.
- Tabib W, Haddad H. Management of second metacarpal chronic osteomyelitis by induced membrane technique. Case Reports Plast Surg Hand Surg. 2018; 5(1): 49-53.
Figure 1: (a,b) XR hand from 12/18/2017
Figure 2: (a,b) XR hand from 2/27/2018
Figure 3: (a,b) XR hand from 4/30/2018
Figure 4: (a,b} XR hand from 6/12/2018
Figure 5: (a,b} XR hand from 11/2018
Figure 6: (a,b,c} Photographs