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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 125-131

Masquelet's induced membrane technique for reconstruction of large extra-articular intercalary bone defect


1 Department of Orthopedic Surgery, Ain Shams General Hospital, Cairo, Egypt
2 Department of Orthopedic Surgery, Zagazig University, Cairo, Egypt
3 Department of orthopaedic surgery Alzahraa University Hospital, Al-Azhar University, Cairo, Egypt
4 Department of Orthopedic Surgery, Al-Azhar University Hospitals, Cairo, Egypt
5 Department of orthopedic Surgery, Johns Hopkins Aramco Hospital, Dhahran, Kingdom of Saudi Arabia
6 Department of Orthopedic Surgery, University of Louisville, Louisville, KY, USA
7 Department of Orthopedic Surgery, Al-Azhar University Hospital, Asyut, Egypt
8 Department of Orthopedic, Texas Tech University, El Paso, TX, USA

Date of Submission14-Oct-2021
Date of Decision11-Nov-2021
Date of Acceptance22-Nov-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Yasser Elbatrawy
Department of Orthopedic Surgery, Faculty of Medicine for Girls, Alzahraa University Hospital, Al-Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_30_21

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  Abstract 


Background: Intercalary bone defects are challenging for both surgeon and patient. The Masquelet's induced membrane technique saves bone consolidation time is less technically demanding than other techniques and achieves good results in the reconstruction of large extra-articular intercalary bone defects. Patients and Methods: This prospective study reviewed 60 patients treated with the induced membrane technique. Patients with femoral or tibial extra-articular intercalary bone defects ≥5 cm long, occurring either posttraumatically or after debridement of infected bone, were included in the study. Patients with bone defects <5 cm long were excluded from the study. The male-to-female ratio was 17:3. Patient age ranged from 10 to 50 years. Recorded outcomes included union, infection, residual deformity, soft-tissue healing, persistent pain, return to previous occupation, permanent joint contracture, and patient satisfaction. Results: Mean follow-up was 3.1 years (range, 2.2–4 years). Mean intercalary bone defect measured 7.5 cm (range, 5–13 cm) in length. Forty-five of 60 patients had open fractures. Thirty-nine underwent Ilizarov fixation, 12 with locked plates, and nine with a limb reconstruction system. The mean interval between the first and second stages was 56 days (range, 42–84 days). Bony union was achieved in 51 patients (85%). Twelve patients experienced relapsed infection during treatment, three because of flap failure, and nine because of inadequate debridement. Three were treated with repeat debridement and free vascularized flap after gastrocnemius flap, six underwent bone transport, and three required amputation. Conclusion: The Masquelet's induced membrane technique was highly effective in achieving the union of large femoral intercalary bone defects, with mixed results in the tibia.

Keywords: Induced membrane technique, lower limb reconstruction, segmental bone defect, union.


How to cite this article:
Soliman ME, Elzohairy MM, AbdelWahab AM, Khaira YM, Elbatrawy Y, Abdalla UG, Mansour SM, Dabash S, Abdellatif Abuomira IE, Thabet AM. Masquelet's induced membrane technique for reconstruction of large extra-articular intercalary bone defect. J Limb Lengthen Reconstr 2021;7:125-31

How to cite this URL:
Soliman ME, Elzohairy MM, AbdelWahab AM, Khaira YM, Elbatrawy Y, Abdalla UG, Mansour SM, Dabash S, Abdellatif Abuomira IE, Thabet AM. Masquelet's induced membrane technique for reconstruction of large extra-articular intercalary bone defect. J Limb Lengthen Reconstr [serial online] 2021 [cited 2022 Dec 2];7:125-31. Available from: https://www.jlimblengthrecon.org/text.asp?2021/7/2/125/334378




  Introduction Top


Management of intercalary bone defects is challenging for both surgeon and patient. It entails special decision-making and surgical skills, lengthy hospitalization and follow-up, high costs, and increased possibilities of functional and psychological disabilities.[1],[2] If the bone defect is >5 cm, autologous bone graft is not advocated because it will be absorbed, resulting in nonunion.[3],[4] For large defects, many treatment options are available, including vascularized bone grafts, bone transport, nonvascularized grafts, allografts, fibular pro-tibia grafting, and titanium mesh cage.[5],[6],[7]

In 1986, Masquelet developed a technique for the reconstruction of large diaphyseal bone defects based on the induction of a membrane by provoking foreign body reactions to cement placed in the bone defect.[8],[9] This induced membrane is highly vascular and acts as a biological chamber that prevents graft resorption by providing vascularization and growth factors.[8],[9]

Our hypothesis was that the induced membrane technique developed by Masquelet is valuable for intercalary bone defects ≤13 cm, as previously reported. We evaluated functional and radiological results and assessed patient satisfaction.


  Patients and Methods Top


This prospective study included patients treated by the Masquelet's induced membrane technique at our university trauma center from January 2016 to December 2019. Included were 60 patients with extra-articular intercalary femoral and tibial bone defects ranging from 5 to 13 cm in length that resulted after acute traumatic bone loss or after debridement of infected bone. The male-to-female ratio was 17:3, and the patient age range was from 10 to 50 years (27.1 ± 10.08 standard deviation). Patients with small bone defects (length <5 cm) were excluded from the study. Follow-up period, cause of initial injury, duration of cement spacer between two stages, type of fixation, complications, and whether union or nonunion occurred were recorded for evaluation.

The mean follow-up period was 3.1 years (range, 2.2–4 years). Of 60 patients, 39 (65%) had light jobs (65%) and 21 (35%) were heavy workers. Thirty percent of the patients were smokers. The femur was affected in 30 cases (50%), and the tibia was affected in 30 cases (50%). The right side was involved in the majority (70%) of cases. Forty-five cases (75%) had open fractures based on Gustilo classification.[10] Defect size was distributed as 8.4 ± 2.74 cm, and the duration of the spacer was 53.4 ± 12.3 days. The cause of bone defect was the acute traumatic bone loss in 39 cases (65%) and infection after debridement in 21 (35%). Polymethyl methacrylate (PMMA) mixed with vancomycin (2 gm) was applied after debridement of infected bone in 21 cases (35%). Regarding the fixation method, the circular Ilizarov frame was used in 39 cases (65%), locked plate in 12 (20%), and limb reconstruction system (LRS; Orthofix, Lewisville, TX, USA) in nine (15%). Of the 39 cases fixed with Ilizarov, a unilateral external fixator was temporarily placed in 15 cases and modification of the Ilizarov frame was performed at the second stage in 18 cases. The bone grafts were autogenous iliac crest bone graft in 36 cases (60%) and anterior iliac crest bone graft plus ipsilateral fibula in 24 (40%). Eighteen cases (30%) needed gastrocnemius flap, six (10%) needed free vascularized latissimus dorsi flap, and three (5%) needed gastrocnemius flap revised with latissimus dorsi flap.

Assessment of the results was conducted using the El-Rosasy evaluation system modified from Paley,[11] [Table 1]. The system includes evaluation of bony union, any residual deformity, any residual limb length discrepancy (LLD), relapsed infection, soft-tissue healing, persistent pain, return to previous occupation, permanent joint contracture, and patient satisfaction. Bony union was defined clinically by the patient's ability to fully bear weight without pain and radiologically by the appearance of at least three cortices. The final results were considered either satisfactory or not according to these findings.
Table 1: Parameters of evaluation of results*

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Surgical technique

The technique involved two stages. The first stage starts with radical debridement of all necrotic and septic soft tissues and bone. Next, length, alignment, and rotation are restored according to preoperative planning. Either external or internal fixation is applied. The decision of whether to use external or internal fixation is case-specific based on many criteria, including surgeon preference, presence or absence of infection, soft tissue damage, skin coverage, and availability of the preferred method of fixation. After fixation is in place, the bone defect is filled with a PMMA cement spacer, either with or without antibiotics. The final step in stage 1 is to cover the defect with a flap, if necessary.[4],[9],[12]

The second stage is performed at least 6–8 weeks after the first stage. After maturation of the induced membrane and subsidence of infection, if present, careful dissection is performed through the previous incision to reach the membrane to be incised longitudinally with a sharp blade. The cement is then removed, either en bloc or in pieces using an osteotome to split it, and the ends of the resected bone and the medullary canal are refreshed with the use of a rasp or a drill bit to remove all sclerotic bone and to facilitate the integration of bone graft. Next, the capsule of the biomembrane undergoes irrigation to remove any residual debris before filling it with small morsels of cancellous bone graft. The last step of stage 2 is to close the membrane with absorbable sutures.[4],[9],[12],[13],[14]

Statistical analysis

Data collected by obtaining patient histories, performing basic clinical examinations, conducting laboratory investigations and recording outcome measures were coded, entered, and analyzed using Microsoft Excel software (Microsoft Corporation, Albuquerque, NM, USA). The information was then imported into Statistical Package for the Social Sciences software (SPSS version 20.0) (SPSS Software, Armonk, NY, USA) for analysis. According to the type of data (qualitative = number and percentage, quantitative = mean ± standard deviation), the following tests were conducted to assess differences for significance: Difference and association of qualitative variable by χ2 test and differences between quantitative independent groups by t-test or Mann–Whitney U-test. The P value was set at <0.05 for significant results and at <0.001 for highly significant results.


  Results Top


Bone union was achieved in 51 patients (85%). Residual deformity ≥5° was present in 12 patients (20%), residual LLD ≥2.5 cm in nine (15%), and relapsed infection in 12 (20%). Moderate to severe pain was present in 12 patients (20%) and permanent joint contracture ≥5° in 18 (30%). Some of the nine patients with residual LLD were satisfied with shoe lifting, and others were scheduled for future lengthening. Relapsed infection during treatment was managed by redoing the first stage of the surgical technique in some cases. It led to flap failure and repeat flap application in three cases. We added vancomycin to the cement spacer in 21 cases. External fixation was applied in cases with infection. Forty-eight patients (80%) returned to their previous occupations. Three cases (5%) required amputation. Forty-eight patients (80%) were satisfied with the results. The dissatisfaction in 12 cases (20%) was significantly associated with tibial defects (P = 0.003) and highly significantly associated with posttraumatic causes of the defects, nonunion, residual deformity, residual LLD, relapsed infection, soft tissue defects, persistent pain, permanent joint contracture, and amputation (P = 0.001) [Figure 1], [Figure 2], [Figure 3], [Figure 4] and [Table 2], [Table 3], [Table 4], [Table 5].
Figure 1: Radiographs of a 13-year-old male patient with a history of a fractured femoral shaft treated with plates and screws. (a) At presentation with failed fixation of plate. (b) After debridement of necrotic bone, removal of plate, and fixation with a unilateral external fixator. (c) After the first stage and cement placement in the bone defect. (d and e) Anteroposterior and lateral views obtained 6 weeks postoperatively show an autogenous bone graft filling the defect and definitive fixation with plate and screws. (f and g) Anteroposterior and lateral views obtained 15 months postoperatively show full bony union

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Figure 2: Clinical photographs. (a) Well-formed membrane (black arrow) surrounds the cement after 2 months. (b) Well-formed membrane, incised longitudinally, remains after cement removal. (c) Bone graft has been placed. (d) Cement is divided into two pieces

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Figure 3: A 21-year-old male patient with posttraumatic bone loss and history of a gunshot wound. (a) Radiograph shows preliminary external fixation. (b) Intraoperative photograph shows cement placement in the bone defect after debridement. (c) Postoperative radiograph obtained after the first stage. (d) Radiograph shows the defect filled with bone graft at the second stage. (e and f) Lateral and anteroposterior views obtained after 12 months show bone union

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Figure 4: Pie chart shows percentage of patient satisfaction. Forty-eight patients (80%) were satisfied with the results. Twelve (20%) were not satisfied

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Table 2: Outcome distribution (n=60)

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Table 3: Patient satisfaction and patient demographics

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Table 4: Patient satisfaction and clinical characteristics

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Table 5: Relation between patient satisfaction and outcome

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  Discussion Top


Intercalary bone defect correction is a major task for orthopedists, especially because of the associated soft tissue injuries. The induced membrane technique provides the defect with a well-vascularized biological chamber resembling the normal periosteum in characteristics and formation, thereby encouraging the incorporation of bone grafts and neo-bone formation. In 2010, Masquelet et al.[4] presented a study of 11 patients with nine tibial, one femoral, and one humeral bone affected. In a study conducted in 2012 by Karger et al.,[9] 61 cases involved the tibia, 13 involved the femur, and six involved the humerus and forearm. In a study conducted in 2016 by Wang et al.,[15] the tibia was affected in 20 cases and the femur in 12. Taylor et al.[16] reported a case study of 69 patients with 35 tibial, 16 femoral, six radial, six humeral, two calcaneal, two first metatarsal, one-fifth metacarpal, and one ulnar bone affected.

Thirty femoral and 30 tibial cases were included in the present study. We found a notable relationship between the affected bone and the outcome: All femoral bones united and all nonunited bones (n = 8) were tibias, suggesting that union is related to bulky soft-tissue coverage, coinciding with the results of other studies.[3],[5],[9] Karger et al.[9] reported that all malunion occurred in the tibia, although the technique is highly recommended for tibial bone defects. The addition of an inter-tibiofibular graft had no substantial influence on the time of union in that study.

In a study conducted by El-Alfy et al.,[17] 13 of 17 cases involved the tibia and four involved the femur. Union was achieved in all femoral cases, and three tibias failed to unite. This is countered by Aurégan et al.[14] who supposed that the tibia has three axes of blood supply: The anterior, posterior, and peroneal arteries. The blood supply surrounds the bone defect and allows rapid maturation of the membrane. The femur, by comparison, has only one main medial axis of blood supply, thereby requiring more time for maturation.

Regarding the size of the bone defect, no notable relationship was observed between size and end result satisfaction. In our study, the length of the defect ranged from 5 to 13 cm, with a mean of 8.4 ± 2.74. In other studies, it ranged from 1.5 to 18 cm[4] and ≤25 cm.[13]

Regarding the condition of the soft tissues, 18 cases (30%) required gastrocnemius flap, six (10%) required free vascularized latissimus dorsi flap, and three (5%) required gastrocnemius flap and then further revision with free latissimus dorsi vascularized flap. All cases requiring flaps were tibial.

In a study conducted by Apard et al.,[18] nine of 12 tibial cases required free muscle flap, two required local muscle flap, and one did not require any flap. In a study conducted by Schöttle et al.[19] in 2005, all six tibial cases required free muscle flap. In a study conducted by Karger et al.[9] in 2012, among 84 cases, 46 flaps were performed before bone reconstruction. In eight of the 46 cases, failure had occurred because of severe lower limb traumas associated with extensive bone and soft tissue defects and infection. Six of the eight cases required amputation. A study conducted by Wang et al.[15] included 20 tibial and 12 femoral cases. Five of the 20 tibial cases required plastic surgery because of skin coverage problems.

In the present study, bone union was achieved in 51 (85%) of 60 cases, coinciding with other studies that reported 80% to 100%.[3],[5],[9] In a pure tibial study, the union rate was as low as 40%.[20]

In our study, the Ilizarov fixator was used in 39 cases (65%), locked plate in 12 (20%), and LRS in nine (15%). No notable relationship was shown between the type of fixation and patient satisfaction.

Relapsed infection occurred in 12 cases (20%) in the present study, three because of flap failure and nine because of inadequate debridement. Three cases (5%) were treated by repeating debridement and using a free vascularized flap after using gastrocnemius flap, six cases (10%) shifted to another technique (bone transport), and three cases (5%) ended in amputation. In a study conducted by Wang et al.[15] in 2016, infection had relapsed in six of 32 cases and required repeat debridement. One case required the third debridement. In a study conducted by Apard et al.,[18] infection recurred in one patient, requiring bone transport. Two cases of infection at the 8th and 24th weeks needed nail change and prolonged antibiotic administration to achieve healing. Masquelet et al.[4] reported early recurrences of infection between the two stages in five cases. Four were treated by repeating debridement and placing a spacer, and one continued to chronic osteomyelitis. Moghaddam et al.[21] reported infection in 35 of 50 cases. The infection healed in 32 cases and had not healed or required amputation in three. El-Rosasy et al.[22] reported no recurrence of infection in a study of 23 patients with infected nonunion of the tibia. Apard et al.[18] supposed that the high rate of delayed infection in their series compared with that reported by Masquelet et al. was because of the use of antibiotic cement, which had masked inadequate debridement that would have been early revised if detected. Masquelet et al. emphasized the role of through debridement and the use of cement without antibiotics, using only prophylactic antibiotics, for this reason.

Patient dissatisfaction with results was markedly associated with tibial defects, especially in acute posttraumatic cases. This might be because of inadequate soft-tissue bulk coverage around the tibia compared with the femur. Adequate soft-tissue bulk coverage provides good nourishment for the maturation of the membrane. We noted better results in femoral cases.

The limitations of the present study are the limited number of cases, short time allowed for the study, and variable causes of bone defects. Posttumor resection and congenital defects were not included. Bones other than the femur and tibia need to be evaluated in future studies. We also recommend further studies comparing the Masquelet technique with different variants. On the other hand, the results support our hypothesis that the induced membrane technique is valuable for the reconstruction of large extra-articular intercalary bone defects.


  Conclusion Top


The Masquelet's induced membrane technique is a good option for the management of large (≤13 cm) intercalary bone defects, achieving a high rate of the bony union in the femur with mixed results in the tibia.

Acknowledgment

The authors thank Dori Kelly, MA, for professional manuscript editing.

Ethical standards

All human studies were approved by the appropriate ethics committee and were therefore performed in accordance with the ethical standards laid down in the 1964 Helsinki Declaration and its later amendments.

Ethical approval

All the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and the 1975 Helsinki Declaration as revised in 2000.

Informed consent

Informed consent was obtained from all the participants included in the present study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wiese A, Pape HC. Bone defects caused by high-energy injuries, bone loss, infected nonunions, and nonunions. Orthop Clin North Am 2010;41:1-4.  Back to cited text no. 1
    
2.
Yu X, Wu H, Li J, Xie Z. Antibiotic cement-coated locking plate as a temporary internal fixator for femoral osteomyelitis defects. Int Othop 2017;41:1851-7.  Back to cited text no. 2
    
3.
Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010;41:27-37.  Back to cited text no. 3
    
4.
Han CS, Wood MB, Bishop AT, Cooney WP III. Vascularized bone transfer. J Bone Joint Surg Am 1992;74:1441-9.  Back to cited text no. 4
    
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Motsitsi N. Masquelet's technique for management of long bone defects: From experiment to clinical application. East Cent Afr J Surg 2012;17:43-7.  Back to cited text no. 5
    
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Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: A review of 25 cases. Injury 2010;41:S72-7.  Back to cited text no. 6
    
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Attias N, Thabet AM, Prabhakar G, Dollahite JA, Gehlert RJ, DeCoster TA. Management of extra-articular segmental defects in long bone using a titanium mesh cage as an adjunct to other methods of fixation: A multicentre report of 17 cases. Bone Joint J 2018;100:646-51.  Back to cited text no. 7
    
8.
Walker M, Sharareh B, Mitchell SA. Masquelet reconstruction for posttraumatic segmental bone defects in the forearm. J Hand Surg Am 2019;44:342.e1-8.  Back to cited text no. 8
    
9.
Karger C, Kishi T, Schneider L, Fitoussi F, Masquelet AC. Treatment of posttraumatic bone defects by the induced membrane technique. Orthop Traumatol Surg Res 2012;98:97-102.  Back to cited text no. 9
    
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Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8.  Back to cited text no. 10
    
11.
El-Rosasy MA. Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia. J Bone Joint Surg Br 2007;89:80-8.  Back to cited text no. 11
    
12.
Chadayammuri V, Hake M, Mauffrey C. Innovative strategies for the management of long bone infection: A review of the Masquelet technique. Patient Saf Surg 2015;9:32.  Back to cited text no. 12
    
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Donegan DJ, Scolaro J, Matuszewski PE, Mehta S. Staged bone grafting following placement of an antibiotic spacer block for the management of segmental long bone defects. Orthopedics 2011;34:e730-5.  Back to cited text no. 13
    
14.
Aurégan JC, Bégué T. Induced membrane for treatment of critical sized bone defect: A review of experimental and clinical experiences. Int Orthop 2014;38:1971-8.  Back to cited text no. 14
    
15.
Wang X, Luo F, Huang K, Xie Z. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res 2016;5:101-5.  Back to cited text no. 15
    
16.
Taylor BC, Hancock J, Zitzke R, Castaneda J. Treatment of bone loss with the induced membrane technique: Techniques and outcomes. J Orthop Trauma 2015;29:554-7.  Back to cited text no. 16
    
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El-Alfy BS, Ali AM. Management of segmental skeletal defects by the induced membrane technique. Indian J Orthop 2015;49:643-8.  Back to cited text no. 17
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18.
Apard T, Bigorre N, Cronier P, Duteille F, Bizot P, Massin P. Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing. Orthop Traumatol Surg Res 2010;96:549-53.  Back to cited text no. 18
    
19.
Schöttle PB, Werner CM, Dumont CE. Two-stage reconstruction with free vascularized soft tissue transfer and conventional bone graft for infected nonunions of the tibia: 6 patients followed for 1.5 to 5 years. Acta Orthop 2005;76:878-83.  Back to cited text no. 19
    
20.
Morris R, Hossain M, Evans A, Pallister I. Induced membrane technique for treating tibial defects gives mixed results. Bone Joint J 2017;99:680-5.  Back to cited text no. 20
    
21.
Moghaddam A, Zietzschmann S, Bruckner T, Schmidmaier G. Treatment of atrophic tibia non-unions according to “diamond concept”: Results of one and two-step treatment. Injury 2015;46:S39-50.  Back to cited text no. 21
    
22.
El-Rosasy M, Mahmoud A, El-Gebaly O, Lashin A, Rodriguez-Collazo E. Debridement technique and dead space management for infected non-union of the tibia. Int J Orthoplastic Surg 2019;2:29-36.  Back to cited text no. 22
    


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