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Die Masquelet-Technik zur Behandlung großer dia- und metaphysärer Knochendefekte

Masquelet technique for the treatment of large dia- and metaphyseal bone defects

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Zusammenfassung

Operationsziel

Behandlung großer dia- und metaphysärer Knochendefekte (> 3 cm) in zwei operativen Eingriffen mit einem zeitlichen Abstand von 4–8 Wochen.

Indikationen

Dia- und metaphysäre Knochendefekte vorwiegend am Unter- und Oberschenkel.

Kontraindikationen

Knochendefekte mit Gelenkbeteiligung, persistierender Knocheninfekt oder Osteomyelitis, insuffiziente Weichteildeckung im Bereich des Knochendefekts, Osteoporose.

Operationstechnik

Ersteingriff: Ausgiebiges Knochendébridement und Weichteildeckung, Einbringen eines Zementspacers in den Knochendefekt zur Induktion einer synovialen Fremdkörpermembran, interne oder externe Stabilisierung. Zweiteingriff: Entfernen des Zementspacers und Füllung des von der induzierten Membran umgebenen Knochendefekts mit autologer Spongiosa, ggf. Verfahrenswechsel auf eine interne Fixation.

Weiterbehandlung

Schmerzabhängige Teil- bis Vollbelastung nach dem Ersteingriff. Abrollende Mobilisation nach dem Zweiteingriff bis zum Auftreten von radiologischen Zeichen eines Remodellings des Regenerats. In der Regel Belassen des Implantats.

Ergebnisse

Insgesamt wurden 6 Patienten (4 Männer, 2 Frauen) im Alter von 15–66 Jahren mit Knochendefekten von durchschnittlich 7 cm (Spanne 4–10 cm) mit der Masquelet-Technik behandelt. Es handelte sich um 2 femorale aseptische Pseudarthrosen und 4 tibiale Pseudarthrosen (je 2 septische und aseptische Pseudarthrosen), dabei in einem Fall um eine periprothetische Pseudarthrose an der Tibia bei schaftgeführter Knieprothese. Die Stabilisierung nach Débridement erfolgte an der Tibia in allen Fällen zunächst mit einem Ringfixateur, am Femur einmal mit einem Marknagel und einmal mit einer winkelstabilen Platte. Der Zweiteingriff wurde zwischen 6 und 9 Wochen nach dem Ersteingriff durchgeführt. Dabei wurde in 3 von 4 Fällen an der Tibia ein Verfahrenswechsel auf eine interne Fixation durchgeführt. Die Spongiosa wurde entweder vom Beckenkamm oder in RIA-Technik („Reamer-Irrigator-Aspirator“) entnommen. Bei der Patientin mit dem periprothetischen Knochendefekt kam es nach 5 Monaten zu einem Plattenbruch und konsekutiver Unterschenkelamputation. In einem Fall wurde aufgrund einer Pseudarthrose an der Andockstelle eine lokale Spongiosaplastik durchgeführt. Alle Patienten waren nach 6 Monaten schmerzfrei und vollbelastend mobil. Der Ilizarov-Fixateur konnte bei einem 15-jährigen Patienten 5 Monate nach dem Zweiteingriff entfernt werden. Die restlichen Implantate wurden belassen.

Abstract

Objective

Treatment of large dia- and metaphyseal bone defects (> 3 cm) with two surgical interventions with an interval of 4–8 weeks.

Indications

Dia- and metaphyseal bone defects predominantly of the lower extremity.

Contraindications

Intraarticular bone defects, persisting bone infection or osteomyelitis, insufficient soft tissue coverage in the region of the bone defect, osteoporosis.

Surgical technique

First surgical intervention: thorough bone debridement and soft tissue coverage, implantation of a cement spacer into the bone defect for the induction of a synovial foreign-body membrane, internal or external fixation. Second surgical intervention: removal of the cement spacer and filling of the bone defect with autologous cancellous bone graft, optionally internal fixation after initial external fixation.

Postoperative management

Partial to full weight-bearing after the first surgical intervention depending on pain. Partial weight-bearing (max. 15 kg) after the second surgical intervention, until radiological signs of a remodeling of the regenerate bone occur. Usually no implant removal.

Results

A total of 6 patients (4 men, 2 women) aged 15–66 years with average bone defects of 7 cm (range 4–10 cm) were treated using the Masquelet technique. There were 2 aseptic femoral nonunions and 4 tibial nonunions (2 septic and 2 aseptic nonunions). One case was a periprosthetic tibial bone defect. Bone stabilization after debridement was performed using ring fixators on the tibia and an intramedullary nail and a locking plate on the femur, respectively. The second surgical intervention was performed after 6–9 weeks. In 3 of the 4 tibial cases, internal fixation was performed during this intervention. The iliac crest and the RIA (reamer–irrigator–aspirator) technique were used for cancellous bone grafting. Amputation after breakage of the plate was necessary in the patient with the periprosthetic bone defect. Nonunion at the docking site required cancellous bone grafting in 1 patient. All 5 patients were able to perform full weight-bearing without pain after 6 months. The Ilizarov fixator was removed 5 months after the second surgical intervention in a 15-year-old patient. None of the other implants were removed.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. D. Krappinger, R.A. Lindtner, M. Zegg, A. Dal Pont und B. Huber geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich

    D. Krappinger MD PhD, R.A. Lindtner, M. Zegg, A. Dal Pont & B. Huber

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  1. D. Krappinger MD PhD
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  2. R.A. Lindtner
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  3. M. Zegg
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  4. A. Dal Pont
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  5. B. Huber
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Correspondence to D. Krappinger MD PhD.

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Krappinger, D., Lindtner, R., Zegg, M. et al. Die Masquelet-Technik zur Behandlung großer dia- und metaphysärer Knochendefekte. Oper Orthop Traumatol 27, 357–368 (2015). https://doi.org/10.1007/s00064-014-0300-9

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  • DOI: https://doi.org/10.1007/s00064-014-0300-9

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