Massive or critical-sized bone defects are of great challenge to cure.Citation1,Citation2 As we know, such massive bone defects are attributed to primary bone loss in severe trauma, or subsequent to surgical resection of segmental osseous lesions.Citation1,Citation3 Nevertheless, it is never easy to restore structural continuity and functional recovery. For smaller size, we can use nonstructural grafting of autologous (usually iliac cancellous bone) or allogeneic bone. However, only distraction osteogenesis (Ilizarov technique) and vascularized bone grafting (usually fibular segment) are definitive methods for segmental defects.Citation1 Up to date, none of the existing reconstructive methods is faultless.
The talented authors, Masquelet and colleagues, introduced induced membrane technique decades ago.Citation3,Citation4 The two-stage technique comprises of primarily filling the space with polymethyl methacrylate (PMMA), and subsequent sufficient bone grafting following membrane maturation and spacer removal. The induced membrane technique features in high union rate, relatively independent of the defect size, few occurrences of complications, therefore, it is gaining popularity in the care of segmental bone defects.Citation1,Citation4 The disadvantage of induced membrane technique is the demand of autologous cancellous bone, which plays a pivotal role in new bone formation.
Alternatively, we can use allogenic bone and bone substitutes partially in the second stage, which are recommended not to exceed a 3:1 ratio of allograft to autograft.Citation1 Even so, the need for plenty of autologous cancellous bone might cause significant damage in donor sites. Can we fill the defect totally with allogenic or even xenogenic bone grafting?
In a recent publication titled “Guided bone regeneration of femoral segmental defects using equine bone graft: an in-vivo micro-computed tomographic study in rats” in the Journal of Investigative Surgery, the authors repaired critical femur defects with a one-stage fashion of Masquelet technique.Citation5 They used resorbable collagen membrane to act as the induced one in the classic Masquelet technique. One of main functions of the membrane is to block fibrous tissue invasion physically to maintain the microenvironment for osteogenesis.Citation6,Citation7 While biologically, the induced membrane contains chemokines and cytokines, including CXCR4, MCP-1, FGF-2, and BMP-2, which are beneficial for recruitment of precursor cells and new bone formation.Citation8 On the contrary, the degradation of resorbable biomaterials might induce detrimental inflammation and harm the repair process.Citation9 However, we should realize that the utilization of synthetic membrane can greatly shorten the treatment period of guided bone regeneration. Definitely, the advancement of novel biomaterials might provide a better biologic membrane in the coming future.Citation9 In the study, the authors used particulate equine bone to fill the defects in the rat model, and found better radiographic results in comparison with rats treated by crushed autologous femur through micro-CT analysis. The positive findings of xenogenic bone grafting in small animals urge us to repeat the experiment in larger animals. The combined use of synthetic membrane and xenogenic bone will ultimately eliminate the challenge of segmental bone defects. In the current study, although the dynamic bone formation as well as biologic processes (bone induction, transduction, and regeneration) have to be further investigated, it sheds light on a new perspective on one-stage Masquelet surgical technique.
DECLARATION OF INTEREST
The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
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