Modified Masquelet Technique Using Allogeneic Graft for a Gustilo-Anderson Type III-A Open Fracture of the Femur with an 8 cm Bone Defect.

The induced membrane technique was initially described by Masquelet et al. in 1986 as a treatment for tibia nonunion; then, it became one of the established methods in the management of bone defects. Several changes have been made to this technique and have been used in different contexts and different methodologies. We present the case of a 16-year-old girl admitted to our department for a polytrauma after a motorcycle accident. She presented a Gustilo III-A open fracture of the right femoral shaft with a large bone defect of 8 centimeters that we treated with a modified Masquelet technique. In the first stage, an Open Reduction and Internal Fixation of the fracture was made using a 4,5 mm Dynamic Compression Plate and a PMMA cement was inserted at the bone defect area. The second stage was done after 11 weeks, and the defect area was filled exclusively with bone allograft from a bone bank. Complete bony union was seen at 60 weeks of follow-up. After the removal of the implants by another surgeon, the patient presented an atraumatic fracture of the neoformed bone that we treated with intramedullary femoral nailing associated with a local autograft using reaming debris. A complete bony union was achieved after 12 weeks with a complete range of motion of the hip and knee. The stability given to the fracture is essential because it influences the quality of the induced membrane and Masquelet has recommended high initial fixation rigidity to promote incorporation of the graft. It is recommended to delay the second stage of this technique after 8 weeks, especially in femoral reconstruction, to optimize the quality of the induced membrane. Several studies used a modified induced membrane technique to recreate a traumatic large bone defect, and all of them used an autologous bone graft alone or an enriched bone graft. In this case, the use of allograft exclusively seems to be as successful as an autologous or enriched bone graft. Now, with the advent of bone banks, it is possible to get an unlimited amount of allograft, so additional research and large studies are necessary before giving recommendations.

Outcomes of a Reimplanted Talus After a Total Open Extrusion.

Total traumatic extrusion of the talus is a severe and disabling ankle injury that requires a high energy trauma. Many treatment options exist and none of them guarantee a successful result. Here, we present the case of a 67-year-old woman who experienced an open total traumatic extrusion of the talus. Based on the principles of open fracture management, we have realized an early administration of antibiotics and tetanus toxoid booster followed by an urgent debridement of the wound. Next, the talus was reimplanted and fixed with a K-wire. This allowed us to avoid the common complication and achieving good clinical outcomes. In our opinion, this is an encouraging and reasonable treatment option unless the talus is grossly contaminated or missing.

Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat a Complex Open (Terrible Triad) Injury of the Elbow: A Case Report.

INTRODUCTION: Treating a complex elbow injury known as the terrible triad, combined with a severe soft tissue trauma, is challenging for most orthopedic surgeons and can lead to permanent disabilities and poor functional outcomes if reconstruction is inadequate. CASE REPORT: A 75-year-old male with a history of high blood pressure was injured in an accident involving agricultural equipment and presented with a triad injury of the left elbow: a posterolateral dislocation combined with fractures of the radial head (Mason-Johnson Type II) and ulnar coronoid process (Morrey Type 1). Fractures to the radial head and ulnar coronoid process and injuries to the lateral collateral ligament and triceps tendon were repaired, and a local skin flap was preserved to provide adequate soft tissue coverage. A hinged external fixator was applied to maintain elbow alignment and allow early mobilization. Traditional negative pressure wound therapy (NPWT) was applied on the remaining skin defects; when local necrosis and septic arthritis of the elbow were noted, NPWT with instillation and dwell time (NPWTi-d) was initiated. Once a viable wound bed was obtained, a split-thickness skin graft was used to provide total coverage. All wounds and fractures were healed within 8 weeks, the external fixator was removed, and free elbow joint mobilization was allowed. At 3 months, the authors obtained 100°/30°/0° of elbow range of motion with a DASH 3 at 30. At 6 months, the elbow range of motion reached 120°/20°/0° with a clear improvement of DASH score (DASH 6 at 14.2). CONCLUSIONS: Management of this complex elbow injury that featured NPWTi-d contributed to a good result and facilitated coverage of an extensive loss of skin and soft tissue; more importantly, the patient experienced limited discomfort. A larger prospective study is required to support general recommendations for this approach to similar injury.

Management of a Severe Degloving Injury With a Type 2 Open Tibia Fracture Using Negative Pressure Wound Therapy With Instillation and Dwell Time.

INTRODUCTION: Severe lower extremity trauma cases are challenging for most orthopedic surgeons if a degloving injury with open fracture is associated, especially in the elderly population. The management of the soft tissue is essential for bone union and reduction of infection. CASE REPORT: The authors present the case of an 87-year-old female admitted to their department after a road accident in which she sustained an open fracture of the distal tibia classified as Gustilo-Anderson Type II, a closed fracture of the lateral malleoli, and a degloving of the posterior and lateral aspect of the left leg. After antibiotic delivery, she underwent surgical debridement and wound irrigation, 5 hours after the accident. The avulsed skin flap was conserved, the fracture of the lateral malleoli was fixed using the minimally invasive plate osteosynthesis technique, and an external fixation was applied for the distal tibia fracture. After 1 week, the necrotic skin flap and muscle were excised, and negative pressure wound therapy with instillation and dwell time (NPWTi-d) was applied for 9 days. Once granulation tissue with healthy wound edges was obtained, a split-thickness skin graft was used to provide total coverage. After 8 weeks, external fixation was replaced by a plaster cast. Eight weeks later, all wounds and fractures were healed, and the patient was able to return to their daily activities. CONCLUSIONS: The authors' main goal was achieved: preserving the architecture of the leg, achieving bone union, and avoiding infection. A large part of this good result comes back to NPWTi-d, a promising treatment that grants clinical benefit for the patient and surgeon. Additional research and larger prospective studies are required before giving a strict recommendation.

Management of a High-Energy Soft Tissue Injury of the Lower Extremity Using Negative Pressure Wound Therapy With Instillation and Dwell Time and a Reticulated Open Cell Foam Dressing.

INTRODUCTION: Soft tissue injuries of the lower extremity are the result of high-energy trauma, such as road accidents, and remain challenging for most orthopedic surgeons. Proper selection of the treatment is important considering the risk of delayed necrosis and wound sepsis. Negative pressure wound therapy (NPWT) has improved complex wound treatment since 1997, but all treatments present advantages and limits. CASE REPORT: A 21-year-old male presented with a high-energy soft tissue injury of the lower extremity. Three days after surgical debridement, complete skin necrosis developed. Successive surgical debridement was done in combination with traditional NPWT for 2 weeks; yet the wound did not progress toward healing, and the bone remained exposed. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) was used with a novel reticulated open cell foam dressing (ROCF-CC) because further surgical debridement was not possible, and the use of NPWT was not recommended by the French high authority for health. Growth of granulation tissue was fast (9 days), even over the bone, without any surgical debridement and despite the presence of nonviable and fibrinous tissue. After that, traditional NPWT was discontinued and a split-thickness skin graft then was used to cover the defects. Four weeks following the accident, all wounds were completely healed. CONCLUSIONS: Surgical debridement remains irreplaceable; however, when debridement is not feasible, NPWTi-d with ROCF-CC might be the treatment of choice. This strategy allowed the authors to ensure coverage of an extensive loss of soft tissue when the traditional NPWT limit was reached.