S. Huard

Reconstruction des pertes de substance osseuse du membre supérieur par la technique de la membrane induite, étude prospective à propos de neuf cas

INTRODUCTION Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique). PATIENTS AND METHODS Nine patients with a mean age of 39.2 years (17-69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1cm (2.5-9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMPs growth factor was used in two cases. RESULTS Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8-52) after the first stage, and 17 months (6-49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones. DISCUSSION The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.

Article originalReconstruction des pertes de substance osseuse du membre supérieur par la technique de la membrane induite, étude prospective à propos de neuf casInduced membrane technique for the reconstruction of bone defects in upper limb. A prospective single center study of nine cases

INTRODUCTION Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique). PATIENTS AND METHODS Nine patients with a mean age of 39.2 years (17-69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1cm (2.5-9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMPs growth factor was used in two cases. RESULTS Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8-52) after the first stage, and 17 months (6-49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones. DISCUSSION The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.

Nouveau traitement de la maladie de Kienböck avancée : remplacement du semi-lunaire par greffon cartilagineux costal

Treatment of advanced Kienböcks disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböcks disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.