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Fascial And Membrane Technique: Comprehensive T...

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Fascial And Membrane Technique: Comprehensive T...

Reconstruction of critical-size bony defects remains a challenge to surgeons despite recent technological advances. Current treatments include distraction osteogenesis, cancellous autograft, induced membranes (Masquelet procedure), polymeric membranes, and titanium-mesh cages filled with bone graft. In this article, the authors presents two cases in which critical-sized defects were reconstructed using a meshed fascial autograft encasing reamer-irrigator-aspirator (RIA) autograft and cancellous allograft. This article will discuss the clinical outcomes of the technique, comparison to other current techniques, and technical insight into the potential biological mechanism.

The main potential advantages of the author's technique include the following: 1) the need for only one operative session, 2) the use of a non-immunogenic graft source, and 3) the "moldability" of a Masquelet pseudomembrane while still offering the barrication/guide of other methods. The fascial graft obviates the need for a second procedure, as the patient's own corpus is a "one-stop shop" for the majority of the reconstruction. Patients who cannot follow-up either due to non-compliance or other circumstances may be suitable candidates for such a one-stage reconstruction. In both described patients, the fascial harvest was quick to perform, and neither patient had any post-operative morbidity or functional limitation from either the ITB or RIA bone graft harvest. Since the bony defect is treated acutely, there is no repeat insult to the soft tissue or bone due to a second procedure. The rationale for the various components of the reconstruction are as follows: the fascial membrane prevents tissue intravasation and serves as a bed/guide for periosteal regeneration; RIA bone graft serves as an osteogenic source of bone marrow stromal cells, and cancellous allograft serves as an osteoconductive scaffold. In the metatarsal reconstruction case, BMP-2 served as an osteoinductive agent. A minimal amount of cancellous allograft was used as "framework" for bone regeneration; thus, it is unclear what ratio of cancellous autograft to allograft is optimal. Although marrow stromal cells (i.e., bone marrow-derived mesenchymal stem cells) have been demonstrated in numerous other tissues, the role of the fascial membrane as a potential source of stem/progenitor cells is unknown. More importantly, as mentioned before, the true value of the membrane, whether polymeric, titanium, or biologic, seems to be its role as a barricade to tissue intravasation and as a bed for periosteal regeneration. The value of the periosteal cambium layer has been clearly demonstrated and membranes seem to improve bone regeneration. For example, Reyenders et al. have demonstrated that non-vascularized periosteal autografts enhance fracture healing of bone defects in a rabbit model, especially when the graft is in contact with intact periosteum [23].

As mentioned previously, polymeric membranes have both acute and long-term inflammatory effects, which have potentially hindered their widespread use. Based on the one-year post-operative CT performed on the second case, it appears that the fascial graft is still intact and not degraded.

Another potential limitation of the technique is possible morbidity associated with the fascial donor site. Although in these two patients there was no morbidity with the fascial graft harvest, studies with larger sample sizes are necessary to establish potential complications. Autologous tissue, if associated with low morbidity, is potentially more beneficial than allogeneic, immunogenic tissue; however, as mentioned before, commercial entities may be sought after for a flexible, collagenous membrane to traverse these defects. If these membranes are effective with no immunogenic reaction, they may preclude the potential morbidity associated with a fascial harvest.

This paper demonstrates a one-stage procedure us


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