CASE REPORT

 

Induced Membrane Technique for Aseptic Recalcitrant Nonunion of the Femur: A Case Report

 

Rafael Amadei, Gonzalo M. Viollaz

Orthopedics and Traumatology Service, Hospital de Alta Complejidad Cuenca Alta “Néstor Kirchner”, Buenos Aires, Argentina

 

ABSTRACT

In aseptic recalcitrant nonunion, failure of bone healing coexists with malalignment and limb length discrepancy. There is still no consensus on the management of these cases. We present the case of a 53-year-old man with aseptic recalcitrant nonunion of the femur treated with the induced membrane technique. He had a history of a closed fracture of the right distal femur (AO 33-A3.3) and two previous surgeries at another institution. He presented with a limb length discrepancy of 3.1 cm, 6° of varus malalignment in the coronal plane, and 8° of internal rotation. After removal of the previous implant and radical debridement, the bone defect measured 4.2 cm. Stabilization was achieved with a retrograde intramedullary nail, and the defect was filled with polymethylmethacrylate cement mixed with vancomycin. In the second stage, the cement was removed, and the defect was filled with a mixture of autograft and allograft. Bone union was confirmed six months after treatment initiation, with filling of the defect and correction of the deformities. Conclusion: The induced membrane technique is a viable option for treating bone defects resulting from aseptic recalcitrant nonunion of the femur.

Keywords: Nonunion; femur; aseptic; Masquelet technique.

Level of Evidence: IV

 

Técnica de membrana inducida para la seudoartrosis aséptica recalcitrante de fémur. Reporte de un caso

 

RESUMEN

En las seudoartrosis asépticas recalcitrantes, coexisten la ausencia de consolidación ósea, la mala alineación y la discrepancia de longitud de miembros. Aún no hay consenso sobre cómo manejar estos casos. Presentamos a un hombre de 53 años con seudoartrosis aséptica recalcitrante de fémur tratada con la técnica de membrana inducida. Tenía antecedente de fractura cerrada del extremo distal del fémur derecho (AO33-A3.3) y dos cirugías en otro centro. Tenía una discrepancia de longitud de los miembros de 3,1 cm, mala alineación coronal en varo de 6° y rotación interna de 8°. Después de retirar el implante previo y el desbridamiento radical, el defecto óseo medía 4,2 cm. Se procedió a la estabilización con clavo endomedular retrógrado y el relleno del defecto con cemento de polimetilmetacrilato más vancomicina. En un segundo tiempo, se retiró el cemento y se rellenó el defecto con mezcla de autoinjerto y aloinjerto. Se comprobó la consolidación ósea a los 6 meses del inicio del tratamiento, con relleno del defecto y corrección de las deformidades. Conclusión: La técnica de membrana inducida es una opción viable para tratar los defectos óseos resultantes en las seudoartrosis asépticas recalcitrantes de fémur.

Palabras clave: Seudoartrosis; fémur; aséptica; técnica de Masquelet.

Nivel de Evidencia: IV

 

INTRODUCTION

Femoral nonunion remains a challenging complication, reported in up to 10% of cases.1 Various treatments have been described for aseptic nonunion, including decortication, revision fixation to improve stability, and bone grafting, with a union rate of 80%.2-4

Nonunion is considered recalcitrant when surgical attempts fail to achieve union.5 Management is difficult because poor bone quality, bone defects, malalignment, limb length discrepancy (LLD), implant fatigue, joint stiffness, scar contractures, skin coverage defects, and infection often coexist.5-8 These factors cause prolonged disability, with adverse effects on social functioning, including job loss, depression, and anxiety, among other consequences. Repeated treatments also impose substantial financial costs on patients, their families, and the healthcare system.7-9

Although evidence on the management of recalcitrant aseptic nonunion (RAN) is limited, numerous surgical strategies have been described, and no consensus has yet been reached. Approaches that provide biological and mechanical stimulation include intramedullary canal reaming with exchange nailing, decortication and plate-and-screw fixation, vascularized bone grafting, and distraction osteogenesis, with variable clinical outcomes.9-13 The induced membrane technique (IMT), also known as the Masquelet technique, is a staged reconstructive procedure frequently used to treat infected bone defects.14

Since its initial description, the technique has gained popularity because of its effectiveness and reproducibility.14-18 In 2020, Masquelet reported its use in cases of RAN with malalignment.18 We therefore present this case to illustrate our experience with the IMT in patients with femoral RAN.

 

 

 

 

 

CASE REPORT

A 53-year-old man had sustained a closed, extra-articular fracture of the right distal femur with diaphyseal extension and comminution (AO 33-A3.3). He had undergone two operations at another institution and presented with RAN 10 months after his last operation and 3 years after the injury. We defined nonunion as the absence of union in three of the four cortices on anteroposterior and lateral radiographs at 9 months after injury, with no radiographic progression of healing over the preceding 3 months (Figure 1).16,19 The nonunion was considered recalcitrant because one or more previous surgical treatments had failed.5

To identify any associated pathogens, laboratory testing, including acute-phase reactants, was performed on two successive occasions, and a needle bone biopsy was obtained. Five specimens were submitted for bacteriological analysis and enrichment culture for 15 days. Both investigations were negative and, according to the Weber classification,20 the nonunion was classified as aseptic.21

A lower-limb scanogram was obtained to assess LLD. Analysis of the images using Synapse software revealed

3.1 cm of shortening of the right lower limb. Computed tomography (CT) was used to assess coronal, sagittal, and rotational alignment, revealing 6° of varus malalignment in the coronal plane and 8° of internal rotation (Figure 2).

 

 

 

 

 

Malalignment and shortening were confirmed clinically (Figure 3). The assessment also included the limb’s neurovascular status, the condition of the soft tissues and previous scars, and the patient’s general health.

 

 

 

 

 

Surgical Technique

With the patient supine, the nonunion site was exposed through the previous lateral thigh incision, and the plate and screws were removed. The devitalized bone segment was resected en bloc until punctate bleeding was seen at the bone ends (paprika sign).22 No tissue findings suggested infection. Given the LLD and malalignment, the procedure was planned with the assistance of a universal femoral distractor (Synthes) (Figure 4).

 

 

 

 

 

The bone defect measured 4.2 cm after debridement. Alignment and limb length discrepancy were corrected according to the preoperative plan using the technique described by Ganz.23 The femur was then stabilized with a retrograde interlocking intramedullary nail (South American Implants). Five bone and soft tissue specimens were again collected for microbiological and histopathological examination. The defect was filled with two batches of polymethylmethacrylate (PMMA) bone cement, each containing 4 g of vancomycin, and the wound was carefully closed in layers (Figure 5). Weight bearing as tolerated was permitted immediately after the first surgical stage.

 

 

 

 

 

The second stage was performed 8 weeks later, with no clinical or microbiological evidence of infection. The nonunion site was re-explored by opening the induced membrane, removing the PMMA spacer, and curetting the inner surface of the newly formed capsule to stimulate bleeding. Tissue specimens were again collected for bacteriological examination, and the defect was filled with autologous bone graft and allograft in a 1:1 ratio (Figures 6 y 7). The membrane was closed with absorbable sutures, followed by the remaining tissue layers. The implant was retained because it remained stable (Figure 8). Weight bearing was restricted for 30 days after the second stage, after which partial weight bearing was permitted until union was confirmed.

 

 

 

 

 

 

 

 

 

 

 

At the final follow-up, 1 year after the last procedure, union and complete graft incorporation were observed, with complete filling of the defect. No further operations were required, and no graft resorption was observed. The LLD was partially corrected, with 1.6 cm of length restored, while coronal and rotational malalignment were fully corrected (Figure 9). The patient regained his functional status and returned to work after treatment (Figure 10).

 

 

 

 

 

 

 

 

DISCUSSION

This case illustrates a potential indication for the IMT in femoral RAN, with both bone union and correction of residual deformities achieved, as previously reported by Masquelet.15

The management of RAN remains a subject of debate. Wiss et al. analyzed 122 femoral nonunions treated with intramedullary nails or plate-and-screw fixation. The union rate was 83.6%, and the reoperation rate was 17.2%. The risk factors identified in that series were infection, smoking, metabolic disorders, and a history of three or more operations.24,25

Since Masquelet first described it, the IMT has evolved to favor internal over external fixation and to incorporate antibiotics into the cement.14-19

In our case, an interlocking intramedullary nail was inserted during the first stage and retained thereafter, providing excellent stability while maximizing patient comfort and facilitating rehabilitation.26,27 Weight bearing was permitted from the outset to help maintain muscle condition and promote proprioception and joint mobility.28 We added vancomycin to the cement because of concern about an undetected low-grade infection. This decision was supported by studies that identified bacterial colonies through RNA sequencing in patients with negative bacterial cultures.29 Some experimental studies also suggest that antibiotics may influence membrane thickness and vascularization,29 both of which are crucial to establishing the microenvironment needed for bone healing, described by Giannoudis as a “bioreactor.”30

This report illustrates another “evolution” of the IMT through its use in RAN. Supporting evidence remains limited; however, Ma reported good outcomes in 12 cases of distal femoral RAN treated with a modified three-stage IMT: 1) debridement and bone lengthening with an external fixator; 2) correction of alignment, placement of a cement spacer, and plate-and-screw fixation; and 3) replacement of the cement with bone graft within the pseudocapsule.31

In our case, a preliminary stage to create the space was unnecessary because we used a femoral distractor for lengthening and manipulation of the nonunion site. This allowed us to manage a 4.2-cm defect without neurovascular complications and correct the existing malalignment during the same procedure.

The main limitation of this report is the lack of scientific evidence supporting the technique. Studies with larger numbers of patients are therefore needed to corroborate this finding. Nevertheless, given the high rate of treatment failure in this condition, we believe that describing a reproducible and effective technique for managing bone defects is valuable. We therefore consider the IMT potentially effective for treating femoral RAN and encourage further investigation to provide stronger evidence supporting its use.

 

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R. Amadei ORCID ID: https://orcid.org/0000-0002-0032-3016

 

Received on March 18th, 2025. Accepted after evaluation on February 16th, 2026 • Dr. GONZALO M. VIOLLAZ • gonzaloviollaz@gmail.com • https://orcid.org/0000-0002-4573-883X

 

How to cite this article: Amadei R, Viollaz GM. Induced Membrane Technique for Aseptic Recalcitrant Nonunion of the Femur: A Case Report. Rev Asoc Argent Ortop Traumatol 2026;91(5):472-482. https://doi.org/10.15417/issn.1852-7434.2026.91.5.2148

 

 

Article Info

Identification: https://doi.org/10.15417/issn.1852-7434.2026.91.5.2148

Published: October, 2026

Conflict of interests: The authors declare no conflicts of interest.

Copyright: © 2026, Revista de la Asociación Argentina de Ortopedia y Traumatología.

License: This article is under Attribution-NonCommertial-ShareAlike 4.0 International Creative Commons License (CC-BY-NC-SA 4.0).