Application and advantages of three-dimensional printing in treatment of masquelet membrane induction for infectious tibial bone defects

Chunwei Wei; Jiayi Chen; Chenxiao Zheng

doi:10.4103/digm.digm_41_21

SHORT COMMUNICATION

Year : 2022 | Volume : 8 | Issue : 1 | Page : 18

Application and advantages of three-dimensional printing in treatment of masquelet membrane induction for infectious tibial bone defects

Chunwei Wei, Jiayi Chen, Chenxiao Zheng
Department of Orthopaedics and Traumatology, Zhongshan Hospital of traditional Chinese Medicine, Zhongshan 528400, China

Date of Submission	20-Sep-2021
Date of Decision	27-Nov-2021
Date of Acceptance	19-Dec-2021
Date of Web Publication	29-Aug-2022

Correspondence Address:
Chenxiao Zheng
Department of Orthopaedics and Traumatology, Zhongshan Hospital of traditional Chinese Medicine, No.3 Kangxin Road, West District, Zhongshan, Guangdong
China

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/digm.digm_41_21

Abstract

In recent years, the treatment of infected tibial bone defects had been a challenge for orthopaedic surgeon. Ilizarov technique had demonstrated its several advantages to repair tibial bone defects, which was recommended by most studies. However, it takes too much time and makes it difficult for patient to persist. Autogenous bone grafts or bone graft substitutes had demonstrated a recognized clinical efficacy, but the existing biomaterials could not meet the clinical requirements including bone induction, structural support, and controllable biodegradability. In order to offer the possibility of individualized treatment, the application of three-dimensional (3D) printing technology in the medical field has been expanding. A 1:1 3D reconstruction model can be used to control the accuracy of implantation in Masquelet's technique for tibial bone defect patients, which could improve the quality and size of induction membrane. However, there are still many disadvantages of its application. Infectious bone defects of the tibia are often frequently accompanied with defect or deficiency of skin, muscle, blood vessels, or some other soft tissues. Moreover, it is difficult to be applied in some hospitals because it requires requirement cooperation of orthopedic surgeons, imaging physicians, and device engineers. This paper reviews the research and application of 3D printing technology in Masquelet membrane induction in patients with infectious tibial bone defect, as well as its clinical advantages and challenges.

Keywords: Infectious tibial bone defect, Masquelet technology, Three-dimensional printing

How to cite this article:
Wei C, Chen J, Zheng C. Application and advantages of three-dimensional printing in treatment of masquelet membrane induction for infectious tibial bone defects. Digit Med 2022;8:18

How to cite this URL:
Wei C, Chen J, Zheng C. Application and advantages of three-dimensional printing in treatment of masquelet membrane induction for infectious tibial bone defects. Digit Med [serial online] 2022 [cited 2023 Jun 9];8:18. Available from: http://www.digitmedicine.com/text.asp?2022/8/1/18/354944

Introduction

Bone defects caused by congenital bone diseases, bone tumors, severe limb trauma, or any other infectious diseases have always been a difficult problem in orthopedic clinics.^[1] With an increase of the number of traffic accidents, severe injury and complicated fracture had been faced commonly in emergency room,^[2] while a large number of patients with the infectious bone defect starting up, which had become the main reason that seriously affect the quality of people's lives and bring heavy burden to society.^[3] Bone defects remains a significant challenge as it requires a large number of autogenous bone grafts or bone graft substitutes.^[4] Although allogeneic bone had been a possible alternative which was widely used abroad, it could not avoid that its disadvantages of causing by immunogenicity rejection, disease transmission, and high cost.^[5],[6] Artificial materials such as metals, synthetic plastics, ceramics, and silicone rubber are difficult to be popularized in clinic due to their lack of bone inductivity. Although there are some problems such as limited source and secondary injury of the donor site, autologous bone transplantation is still the most ideal treatment for bone defects. As an effective treatment for infectious bone defects, Masquelet membrane induction technique has the advantages of extensive indications and not limited by the size of the defect, meanwhile, the disadvantages had been exposed that is difficult to control the size of spacer and ensure the time of healing. If the induction membrane formation is smaller than it needs, the bone connection formed by the graft would not meet the bone repair conditions. It is difficult to remove the antibiotic-filled bone cement during the second operation, and easy to damage the membrane during the removing.

The Advantages of Masquelet Induction Membrane

The three-dimensional (3D) printing technology in medicine is becoming fashionable. It would provide a high precision spacer made by some materials which were easy to acquire, depending on high-quality radiographic imaging data from mirror images of the healthy side, with the assistance of computer's design and manufacturing.^[7] By controlling the accuracy of implantation in Masquelet's membrane induction technique, 3D printing can improve the quality and size of the induction membrane, which may improve the efficacy for infectious tibial bone defects. In particular, the preparation of antibiotic bone cement is of great significance when the Masquelet membrane induction technique is performed on patients with infectious tibial bone defect. In recent years, 3D printing technology has been applied more and more widely in clinical practice and achieved satisfactory consequences, which bringing a new way for the reconstruction of infectious tibial bone defects [Figure 1].^[8],[9]

Figure 1: (01) computerized tomography scans of the patient's bone are acquired. (02) Computer aided software enables the processing of computerized tomography images in order to (03) three-dimensional print personalized scaffolds for (04) bone defect reconstruction. The lower panel illustrates a real large bone defect reconstruction in a sheep metatarsal bone model

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The Disadvantages: Masquelet Induction Membrane Formation

First, traditional technique of Masquelet membrane induction has some blindness in cementing. In traditional application, Vivo cementing fills the bone defect before it sets and wraps around the broken end of the fracture, allowing it to set naturally.^[10] In the second stage of the operation, it was found that the bone cement was firmly connected to the broken end of the bone. There would be a large hole occupied by the cement, easily damaging the induction membrane and bone tissue at the cement-bone interface when removing the cement, which may affected the fracture healing in the second stage of bone grafting.^[11] Second, the heat released during the solidification of bone cement could also affect adjacent bones and tissues, sometimes with permanent damage. To overcome the defects of bone cement in vivo modeling, some scholars have made bone cement in vitro modeling and achieved certain effects.^[12] However, there are various types of bone defects, and it is difficult to reflect the information of bone defects comprehensively and accurately without the imaging data. They varied in size, shape, thickness, and bone composition, which related the implants to the personal experience of physicians. Therefore, the implantation of antibiotic bone cement is one of the key links of this technology.^[13] Third, when debriding osteosclerosis around bone defect area, in order to ensure the efficacy, we usually need to move out more than 5 mm of normal bone tissue to provide a fundamental bone tissue for bony ingrowth.^[14] So as to make it more difficult to estimate the defects accurately, while 3D printing technology would provide a suited spacer despite any size or type of defects.^[15]

Application Of Three-Dimensional Printing In Masquelet Technology

The defect of tibia could be reconstructed by 3D printing technology, with the bone cement model printed according to the computerized tomography data of the defect area.^[11] First, the use vitro model would reduce the thermal damage of bone and soft tissue caused by bone cement solidification, as well as avoid the connections between bone cement and broken end. The multi-module design also avoids the problem of difficult removal of large bone cement that would easily damage the induction film, which could guarantee the quality of the membrane.^[16] Second, the repair and treatment of infectious tibial bone defects, especially large segment bone defects, has always been a problem because of it's difficult to estimate the shape and size. In 3D technology, the shape and size of bone cement and calcaneus bone should be highly consistent, which not only conforms to the biomechanical conduction of defect area but also ensures the formation of induction film in appropriate size. As a result, the preparation of cement is no longer influenced by the physician's experience, and the formation of bubbles and delamination during the cement solidification process could be reduced. Therefore, 3D printing technology combined with Masquelet technology could ensure the quality of the induction membrane, which has efficient technical and biomechanical advantages. Third, there are some problems such as a long treatment cycle, iatrogenic injury, bone defects at the donor site, stress fracture at the recipient site, and so on. With the development of 3D technology, the problems above could be solved or avoided. In other ways, 3D printing technology could also calculate the volume of defect and print a model of defect to perform surgical rehearsal. It will help doctors to understand anatomy and plan a surgical process before the surgery which could make the operation more accurate and minimal invasive, with fewer postoperative complications.^[17]

Difficulties and Deficiencies

With certain advantages and efficacy, 3D printing technology has been applied clinically for bone defects of upper and lower limb, acetabular bone, skull bone, and others. However, there are some problems still need to be solved. For instance, infectious bone defects of the tibia are often caused by severe accident, frequently accompanied with defect or deficiency of skin, muscle, blood vessels or some others soft tissues. Whether these soft tissue defects can be repaired affect the success of bone defects repair. However, there are few clinical studies focus on the problem of soft tissue defects, which should be the research direction of the application of 3D printing technology in the future. Moreover, the related operations often require the cooperation of orthopedic surgeons, imaging physicians, and device engineers,^[18] making it difficult to be applied in some hospitals. As 3D printing technology had been more and more widely applied in clinical practice, the long-term therapeutic efficacy would be further reflected, and the relevant laws and regulations, or other documents should be issued as soon as possible. Finding a kind of implant material with high quality, high performance, and low price would become an important direction of 3D printing technology.

Summary and Outlook

3D printing technology could be completed faster, more accurate when generating any type and size of spacer. The 3D printing technology had been more and more widely used in the clinic with satisfactory results, bring a new way for the reconstruction of bone defect in tibia, while the technology remains some problems that needed to be solved. In conclusion, with the increasing proficiency of clinicians and the emerging new invention of high-performance and low-cost materials, 3D printing technology and that combined with other repair technologies would have a broader application in the treatment of bone defect.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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