A retrospective cohort study on the clinical effectiveness of the modified masquelet technique with platelet-rich plasma for large infected bone defects.

Abstract

To evaluate the safety and efficacy of combining platelet-rich plasma (PRP) with a modified Masquelet technique for reconstructing segmental infected bone defects larger than 6 cm following trauma. A retrospective analysis was performed on 32 patients with large post-traumatic infected bone defects treated at our institution between January 2016 and September 2023. All patients underwent a two-stage procedure: Stage I involved thorough debridement with preservation of bone bridges, implantation of antibiotic-loaded PMMA bone cement, and stabilization using external fixation. Stage II, performed 6-8 weeks later, consisted of cement spacer removal, implantation of a PRP-autologous iliac bone graft mixture into the induced membrane cavity, and conversion to internal fixation. Outcome measures included bone healing time and rate, postoperative pain (VAS), reconstruction outcomes (Paley score), limb-specific function (DASH and LEFS), quality of life (SF-36), correlation between defect length and healing time, and subgroup comparisons of healing time (flap vs. non-flap, bone bridge preservation vs. absence). This study applied the Fracture-Related Infection (FRI) classification to systematically characterize patients' bone defect (F), host-related comorbidities (R), and soft tissue impairment (I) prior to treatment. All 32 patients completed follow-up. FRI classification revealed F4 bone status in all patients (32/32, 100%). R-status was R1 (no related comorbidities) in 28 patients (87.5%) and R2 (presence of related comorbidities) in 4 patients (12.5%). I-status was I2 (Direct wound closure possible but cover of bone and/or implant is fragile) in 16 patients (50.0%) and I3 (Soft tissue reconstruction is required with local tissue transfer) in 16 patients (50.0%). Bone union was achieved in all cases, with a mean healing time of 5.6 ± 0.8 months (range: 4.0-7.0). The Paley score showed an excellent-to-good rate of 90.6%. All functional scores improved significantly postoperatively (P < 0.001): VAS decreased from 7.7 ± 0.7-2.5 ± 0.7; LEFS increased from 33.0 ± 2.9-68.0 ± 2.9; DASH decreased from 62.2 ± 3.2-17.7 ± 2.8; and SF-36 physical function improved from 43.6 ± 4.0-78.2 ± 4.6. The overall complication rate was 18.8% (6/32), including donor site pain (3 cases, 9.4%), joint stiffness (2 cases, 6.3%), and superficial infection (1 case, 3.1%). There were no cases of nonunion or deep infection. Defect length did not correlate with healing time (r = 0.03, P = 0.86). Healing time was significantly shorter in the non-flap group versus the flap group (mean difference: 0.7 months, P = 0.003) and in the bone bridge preservation group versus the absence group (mean difference: 1.0 months, P = 0.001). The combined use of PRP and the modified Masquelet technique is a safe and effective strategy for managing large infected bone defects, leading to significant improvements in limb function and quality of life. This three-component approach-incorporating bone bridge preservation, PRP augmentation, and staged internal fixation-constitutes a comprehensive and promising treatment paradigm worthy of further validation in prospective multicenter studies.