Modified Masquelet Technique with Resorbable Antibiotic Cement and Biologic Dressings
Masquelet and colleagues introduced the Masquelet Technique in 2000, a 2-stage surgical procedure intended for use in large segmental bone defects, often resulting from trauma or infection.1 The first stage of the process involves removing diseased or damaged bone and then implanting a cement spacer, poly(methyl methacrylate) (PMMA), into the bone defect. Masquelet and team described the formation of a bioactive membrane rich in osteogenic factors which promotes vascularization and bone regeneration.1 After period of time, initiation of the second stage involves removing the cement spacer and implanting a bone graft to fill the space.1 The biologically active environment created by the induced membrane facilitates new bone formation within the bone graft and the technique showed promising results in achieving bone union and functional recovery.1
PMMA is a commonly used cement that, when mixed with antibiotics, can deliver that antibiotic therapy directly to an infected site. The use of PMMA bone cement has disadvantages, however, which include the release of methyl methacrylate (MMA) and high exothermic temperature during PMMA polymerization, which can cause thermal necrosis. It is not resorbable, and therefore requires a second surgery for removal. This type of cement can also become a nidus for infection if colonized by bacteria.2,3,4 Resorbable bone cements, such as calcium sulfate, have the advantage of being completely resorbable, therefore they do not require additional surgery to remove and do not act a nidus for infection.5 A wide range of antibiotics can be loaded into antibiotic cement depending on the target organism, including vancomycin and gentamycin.2
Stimulan Rapid Cure (Biocomposites) beads are manufactured from medical grade calcium sulfate as a bone void filler for voids or gaps that are not intrinsic to the stability of the bony structure.5 In bone voids, it serves as a bone graft substitute which resorbs and is replaced with bone during the healing process.5 It is engineered through a special, multistep, more than 6 week recrystallization method.6 It is completely absorbable, contains no hydroxyapatite, PMMA, or insoluble impurities, and is demonstrated to not act as a nidus for infection.4, 7-12
PalinGen XPlus hydromembrane (Amnio Technology) is chemically cross-linked with extracellular matrix fibers and PalinGen Flow is cryopreserved liquid amniotic allograft.13 These amniotic allografts contain collagen types I, III, IV, V, and VII, hyaluronic acid, fibronectin, cytokines, laminin, fibrinogen, proteoglycans, tissue inhibitors of metalloproteinases (TIMPs), amino acides, extracellular matrix proteins and mesenchymal stem cells.14 Amniotic allografts also include key growth factors.15 Amniotic tissues can also differentiate into multiple different types of cell lineages.15-21 These particular options are derived exclusively from the amnion and are chorion-free.15-21
The this case study was to highlights a modified Masquelet Technique utilizing calcium sulfate resorbable antibiotic loaded cement and combination therapy using amniotic allografts and synthetic extracellular matrix dressings as a therapeutic option to manage foot ulcerations with osteomyelitis to maintain length following resection of the diseased bone and to achieve wound closure.
Details of the Patient Case
A 75-year-old male with a past medical history of type 2 diabetes, peripheral neuropathy, and hemodialysis-dependent kidney failure presented with a diabetic foot ulceration (DFU) on the plantar aspect of the left hallux interphalangeal joint that had been present for nearly 5 months. He had no known allergies and no pertinent surgical or social history other than former tobacco use.
Physical examination demonstrated nonpalpable pedal pulses and complete loss of protective sensation. There was no gross deformity of the foot besides pes planus, and the patient ambulated without ambulatory aids. Notably, the patient was awaiting kidney transplant, contingent on healing of his foot ulceration. The patient reported no pain from the ulceration, likely due to peripheral neuropathy. The ulcer measured 2.7 cm x 2.0cm x 0.7cm with exposed bone and deep tissues. No tunneling, undermining, or sinus tract was present. There was purulent drainage, malodor, periwound calor, erythema, and edema, however. The wound bed was a mix of fibrotic and granular tissue.
Doppler examination of the pedal arteries demonstrated multiphasic waveforms. A computed tomography scan and radiographs of the left foot revealed evidence of osteomyelitis in the hallux proximal phalanx head and hallux distal phalanx base, including pathologic fracturing, and concerning findings for septic arthritis of the hallux interphalangeal joint. Glycosylated hemoglobin had a reported value of 6.9%. Wound swab and bone biopsy revealed methicillin-sensitive Staphylococcus aureus (MSSA). The patient began oral antibiotic therapy with doxycycline, continued throughout the duration of treatment.
Next Treatment Steps
The patient then underwent excision of the left hallux interphalangeal joint, including the head of the proximal phalanx and base of the distal phalanx. The resected diseased bone was sent for surgical pathology and culture/sensitivity testing. We then formed resorbable antibiotic cement mixed with antibiotics into the shape of the resected bone to achieve anatomic length. We implanted amniotic allografts into the surrounding tissues, followed by synthetic extracellular matrix dressings overtop.
The patient had weekly follow-ups. At each visit, we removed the resorbable antibiotic cement spacer was removed and either cleansed and reimplanted the spacer, or created a new one for insertion. The necessary size of resorbable antibiotic cement spacer progressively got smaller as it resorbed and soft tissue grew in to fill the space. We also implanted amniotic allografts and synthetic extracellular matrix dressings each time into the wound surrounding the resorbable antibiotic cement spacer.
In order to record wound volume, we calculated this at each visit as the product of the length, width, and depth in cubic centimeters (cm3). Wound sizes were compared to the initial wound size and expressed as a percentage of wound closure. Our goal of therapy was to achieve greater than 95% wound volume decrease.15 Vancomycin was the chosen antibiotic loaded into the resorbable bone cement. Offloading was via an Motus 2.0 (Optima Molliter) boot and a knee scooter.
Notes on the Wound Trajectory
One week following the procedure, the wound volume had decreased by 49%. At 3 weeks, wound volume had decreased by 71% and at 5 weeks by 93%. At 7 weeks, the wound achieved 98% closure. At week 9, the wound was fully closed and healed, and the patient was accepted for kidney transplant.
Final Thoughts
Radiographs obtained at the end of therapeutic period demonstrated no new osseous erosions concerning for osteomyelitis and throughout the course of the therapy no new soft tissue infections occurred. We had the privilege of caring for this patient during a critical time in their health journey. Since then, they have successfully undergone a kidney transplant and are now thriving, free of ulceration and enjoying a renewed quality of life.
Based on our experience, we feel the outcome of this case report supports the use of antibiotic loaded cement in combination with amniotic allografting and synthetic extracellular matrices as a therapeutic option to manage foot ulcerations with osteomyelitis and maintain bone length following resection and to achieve wound closure.
Disclosures
The authors of this article declare no conflict of interest. The companies involved had no role in the design of the study; in the collection, analyses, or interpretation of date; in the writing of the manuscript, or in the decision to publish the results.
It is important to note that this case was performed at the Southern Arizona Veteran Affairs Health Care System, therefore cost and reimbursement were not factors in determining treatment. Anthem Wound Matrix is branded specifically for the Department of Veteran Affairs. In private and commercial, it is branded as Phoenix Wound Matrix. Antibiotic loaded resorbable cement pellets and synthetic extracellular matrices are all reimbursable through Medicare and private insurance and have their own designated HCPCS codes. The cost to benefit ratio would need to be assessed on an individual provider and patient basis. All pricing of the wound care products used in this case are available to the public through the Department of Veteran Affairs Federal Supply Schedule.
Acknowledgements
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, and Office of Research and Development. The authors gratefully acknowledge the Southern Arizona VA Health Care System which provided facilities and materials for this research.
Dr. Evensen is a podiatrist in the Department of Veteran Affairs at Southern Arizona Veteran Affairs Healthcare System in Tuscon, AZ.
Dr. Lin and Dr. Curbo are resident podiatrists in the Department of Veteran Affairs at Southern Arizona Veteran Affairs Healthcare System in Tuscon, AZ.
Dr. Dancho is a podiatrist in the Department of Veteran Affairs at Southern Arizona Veteran Affairs Healthcare System in Tuscon, AZ.
References
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