• Ilaria Morelli, Lorenzo Drago, David A George, Enrico Gallazzi, Sara Scarponi, and Carlo L Romanò.
• Department of Reconstructive Surgery and Osteo-articular Infections C.R.I.O. Unit, I.R.C.C.S. Galeazzi Orthopaedic Institute, Via R. Galeazzi 4, 20161, Milan, Italy; Università degli Studi di Milano, via Festa del Perdono 7, 20122 Milano, Italy. Electronic address: ilaria.morelli90@gmail.com.
• Injury. 2016 Dec 1; 47 Suppl 6: S68-S76.

IntroductionThe induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union.MethodsA systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords "Masquelet technique" and "induced membrane technique". Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients' clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data.ResultsSeventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001).DiscussionIMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis.ConclusionFurther studies are needed to demonstrate the role the patients' clinical features and IMT variants have upon achieving bone union and infection eradication.Copyright © 2016 Elsevier Ltd. All rights reserved.

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