Effectiveness of three-dimensional-printed microporous titanium prostheses combined with flap implantation in treatment of large segmental infectious bone defects in limbs_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 XU Yongqing ¹ , FAN Xinyu ¹ , WANG Teng ¹ , PU Shaoquan ¹ , CAI Xingbo ¹ , SHI Xiangwen ¹ , LIN Wei ¹ , YANG Xi ¹ , LI Jian ² , LIU Min ²

1. Institute of Orthopedic Trauma, 920th Hospital of Chinese PLA Joint Logistics Support Force, Kunming Yunnan, 650032, P. R. China;
2. Beijing Aikang Yicheng Medical Equipment Co., Ltd, Beijing, 102200, P. R. China;

Corresponding author：

XU Yongqing, Email: xuyongqingkm@163.net

Keywords：

Three-dimensional-printing; microporous titanium prostheses; flap; infectious bone defects

DOI：

10.7507/1002-1892.202502045

Video：

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Objective To analyze the effectiveness of single 3D-printed microporous titanium prostheses versus flap combined prostheses implantation in the treatment of large segmental infectious bone defects in limbs. Methods A retrospective analysis was conducted on the clinical data of 76 patients with large segmental infectious bone defects in the limbs who were treated between January 2019 and February 2024 and met the inclusion criteria. Among them, 51 were male and 25 were female, with an age of (47.7±9.4) years. Of the 76 patients, 51 had no soft tissue defects (single prostheses group), while 25 had associated soft tissue defects (flap combined group). The single prostheses group included 28 cases of tibial bone defects, 11 cases of femoral defects, 5 cases of humeral defects, 4 cases of radial bone defects, and 3 cases of metacarpal and carpal bone defects, with bone defect lengths ranging from 3.5 to 28.0 cm. The flap combined group included 3 cases of extensive dorsum of foot soft tissue defects combined with large segmental metatarsal bone defects, 19 cases of lower leg soft tissue defects combined with large segmental tibial bone defects, and 3 cases of hand and forearm soft tissue defects combined with metacarpal, carpal, and radial bone defects, with bone defect lengths ranging from 3.8 to 32.0 cm and soft tissue defect areas ranging from 8 cm×5 cm to 33 cm×10 cm. In the first stage, vancomycin-loaded bone cement was used to control infection, and flap repair was performed in the flap combined group. In the second stage, 3D-printed microporous titanium prostheses were implanted. Postoperative assessments were performed to evaluate infection control and bone integration, and pain recovery was evaluated using the visual analogue scale (VAS) score. Results All patients were followed up postoperatively, with an follow-up time of (35.2±13.4) months. In the 61 lower limb injury patients, the time of standing, walk with crutches, and fully bear weight were (2.2±0.6), (3.9±1.1), and (5.4±1.1) months, respectively. The VAS score at 1 year postoperatively was significantly lower than preoperatively (t=−10.678, P<0.001). X-ray films at 1 year postoperatively showed that in 69 cases (90.8%), the prostheses-bone interface was well integrated, with no complication such as infection, fractures, prostheses displacement or breakage, or nerve damage. According to the Paley scoring system for the healing of infectious bone defects, the results were excellent in 37 cases, good in 29 cases, fair in 3 cases, and poor in 7 cases. In the single prostheses group, during the follow-up, there was 1 case each of femoral prostheses fracture, femoral infection, and tibial infection, with a treatment success rate of 94.1% (48/51). In these patients, the time of fully bear weight was (5.0±1.0) months. In the flap combined group, during the follow-up, 1 case of tibial fixation prostheses screw fracture occurred, along with 2 cases of recurrent foot infection in diabetic patients and 1 case of tibial infection. The treatment success rate was 84.0% (21/25), and the time of fully bear weight was (5.8±1.2) months. The overall infection eradication rate for all patients was 93.4% (71/76). Conclusion The use of 3D-printed microporous titanium prostheses, either alone or in combination with flaps, for the treatment of large segmental infectious bone defects in the limbs results in good effectiveness with a low incidence of complications. It is a feasible strategy for the reconstruction of infectious bone defects.

1.	Papakostidis C, Giannoudis PV. Reconstruction of infected long bone defects: Issues and Challenges. Injury, 2023, 54(3): 807-810.
2.	Liodakis E, Pacha TO, Aktas G, et al. Biological reconstruction of large bone defects : Masquelet technique and new procedures. Unfallchirurgie (Heidelb), 2023, 126(3): 184-189.
3.	Pederiva D, De Luca L, Faldini C, et al. Masquelet’s induced membrane technique in the upper limb: a systematic review of the current outcomes. J Orthop Traumatol, 2025, 26(1): 4. doi: 10.1186/s10195-024-00815-w.
4.	Norris BL, Vanderkarr M, Sparks C, et al. Treatments, cost and healthcare utilization of patients with segmental bone defects. Injury, 2021, 52(10): 2935-2940.
5.	Kanakaris NK, Harwood PJ, Mujica-Mota R, et al. Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique. Eur J Trauma Emerg Surg, 2023, 49(2): 951-964.
6.	Palmquist A, Jolic M, Hryha E, et al. Complex geometry and integrated macro-porosity: Clinical applications of electron beam melting to fabricate bespoke bone-anchored implants. Acta Biomater, 2023, 56: 125-145.
7.	Ivanovski S, Breik O, Carluccio D, et al. 3D printing for bone regeneration: challenges and opportunities for achieving predictability. Periodontol 2000, 2023, 93(1): 358-384.
8.	Jing Z, Yuan W, Wang J, et al. Simvastatin/hydrogel-loaded 3D-printed titanium alloy scaffolds suppress osteosarcoma via TF/NOX2-associated ferroptosis while repairing bone defects. Bioact Mater, 2023, 33: 223-241.
9.	Hotchkiss KM, Reddy GB, Hyzy SL, et al. Titanium surface characteristics, including topography and wettability, alter macrophage activation. Acta Biomater, 2016, 31: 425-434.
10.	Chappell AG, Ramsey MD, Dabestani PJ, et al. Vascularized bone graft reconstruction for upper extremity defects: A review. Arch Plast Surg, 2023, 50(1): 82-95.
11.	Piñal FD. Bone grafts and flaps in the management of complex upper-extremity defects: Indications and outcomes. Clin Plast Surg, 2024, 51(4): 515-526.
12.	Liu B, Tan Q, Wang Z, et al. Applying 3D-printed porous Ti6Al4V prostheses to repair osteomyelitis-induced partial bone defects of lower limbs: Finite element analysis and clinical outcomes. Orthop Surg, 2025, 17(1): 115-124.
13.	杨银, 徐永清, 李刚, 等. 3D打印微孔钛(钽)假体重建下肢骨髓炎致大段骨缺损的疗效分析. 中华创伤骨科杂志, 2024, 26(3): 247-254.
14.	徐永清, 范新宇, 王腾, 等. 皮瓣加3D打印微孔钛(钽)假体治疗下肢软组织缺损伴大段骨缺损. 中华显微外科杂志, 2022, 45(1): 21-27.
15.	Chen Z, Xing Y, Li X, et al. 3D-printed titanium porous Prostheses combined with the Masquelet technique for the management of large femoral bone defect caused by osteomyelitis. BMC Musculoskelet Disord, 2024, 25(1): 474. doi: 10.1186/s12891-024-07576-x.
16.	Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res, 1989(241): 146-165.
17.	Chen Z, Yang Y, Liu B, et al. Application of 3D-printed porous Prostheses for the reconstruction of infectious bone defect with concomitant severe soft tissue lesion: a case series of 13 cases. BMC Musculoskelet Disord, 2024, 25(1): 1090. doi: 10.1186/s12891-024-08248-6.
18.	Meselhy MA, Kandeel M, Halawa AS, et al. Infected tibial nonunion: Assessment of compression distraction Ilizarov technique without debridement. Orthop Traumatol Surg Res, 2021, 107(8): 102881. doi: 10.1016/j.otsr.2021.102881.
19.	Khaled A, El-Gebaly O, El-Rosasy M. Masquelet-Ilizarov technique for the management of bone loss post debridement of infected tibial nonunion. Int Orthop, 2022, 46(9): 1937-1944.
20.	徐永清, 朱跃良, 林玮, 等. 双处截骨纵向搬移治疗长段小腿感染性复合缺损. 生物骨科材料与临床研究, 2018, 15(5): 14-17.
21.	Tong K, Zhong Z, Peng Y, et al. Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis. Injury, 2017, 48(7): 1616-1622.
22.	Metaoy S, Rusu I, Pillai A. Adjuvant local antibiotic therapy in the management of diabetic foot osteomyelitis. Clin Diabetes Endocrinol, 2024, 10(1): 51. doi: 10.1186/s40842-024-00200-w.
23.	Shen D, Huang K, Guo Q, et al. The efficacy of local antibiotic delivery systems therapy in the management of diabetic foot osteomyelitis: A systematic review and meta-analysis. Int J Low Extrem Wounds, 2024. doi: 10.1177/15347346241266062.

1. Papakostidis C, Giannoudis PV. Reconstruction of infected long bone defects: Issues and Challenges. Injury, 2023, 54(3): 807-810.
2. Liodakis E, Pacha TO, Aktas G, et al. Biological reconstruction of large bone defects : Masquelet technique and new procedures. Unfallchirurgie (Heidelb), 2023, 126(3): 184-189.
3. Pederiva D, De Luca L, Faldini C, et al. Masquelet’s induced membrane technique in the upper limb: a systematic review of the current outcomes. J Orthop Traumatol, 2025, 26(1): 4. doi: 10.1186/s10195-024-00815-w.
4. Norris BL, Vanderkarr M, Sparks C, et al. Treatments, cost and healthcare utilization of patients with segmental bone defects. Injury, 2021, 52(10): 2935-2940.
5. Kanakaris NK, Harwood PJ, Mujica-Mota R, et al. Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique. Eur J Trauma Emerg Surg, 2023, 49(2): 951-964.
6. Palmquist A, Jolic M, Hryha E, et al. Complex geometry and integrated macro-porosity: Clinical applications of electron beam melting to fabricate bespoke bone-anchored implants. Acta Biomater, 2023, 56: 125-145.
7. Ivanovski S, Breik O, Carluccio D, et al. 3D printing for bone regeneration: challenges and opportunities for achieving predictability. Periodontol 2000, 2023, 93(1): 358-384.
8. Jing Z, Yuan W, Wang J, et al. Simvastatin/hydrogel-loaded 3D-printed titanium alloy scaffolds suppress osteosarcoma via TF/NOX2-associated ferroptosis while repairing bone defects. Bioact Mater, 2023, 33: 223-241.
9. Hotchkiss KM, Reddy GB, Hyzy SL, et al. Titanium surface characteristics, including topography and wettability, alter macrophage activation. Acta Biomater, 2016, 31: 425-434.
10. Chappell AG, Ramsey MD, Dabestani PJ, et al. Vascularized bone graft reconstruction for upper extremity defects: A review. Arch Plast Surg, 2023, 50(1): 82-95.
11. Piñal FD. Bone grafts and flaps in the management of complex upper-extremity defects: Indications and outcomes. Clin Plast Surg, 2024, 51(4): 515-526.
12. Liu B, Tan Q, Wang Z, et al. Applying 3D-printed porous Ti6Al4V prostheses to repair osteomyelitis-induced partial bone defects of lower limbs: Finite element analysis and clinical outcomes. Orthop Surg, 2025, 17(1): 115-124.
13. 杨银, 徐永清, 李刚, 等. 3D打印微孔钛(钽)假体重建下肢骨髓炎致大段骨缺损的疗效分析. 中华创伤骨科杂志, 2024, 26(3): 247-254.
14. 徐永清, 范新宇, 王腾, 等. 皮瓣加3D打印微孔钛(钽)假体治疗下肢软组织缺损伴大段骨缺损. 中华显微外科杂志, 2022, 45(1): 21-27.
15. Chen Z, Xing Y, Li X, et al. 3D-printed titanium porous Prostheses combined with the Masquelet technique for the management of large femoral bone defect caused by osteomyelitis. BMC Musculoskelet Disord, 2024, 25(1): 474. doi: 10.1186/s12891-024-07576-x.
16. Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res, 1989(241): 146-165.
17. Chen Z, Yang Y, Liu B, et al. Application of 3D-printed porous Prostheses for the reconstruction of infectious bone defect with concomitant severe soft tissue lesion: a case series of 13 cases. BMC Musculoskelet Disord, 2024, 25(1): 1090. doi: 10.1186/s12891-024-08248-6.
18. Meselhy MA, Kandeel M, Halawa AS, et al. Infected tibial nonunion: Assessment of compression distraction Ilizarov technique without debridement. Orthop Traumatol Surg Res, 2021, 107(8): 102881. doi: 10.1016/j.otsr.2021.102881.
19. Khaled A, El-Gebaly O, El-Rosasy M. Masquelet-Ilizarov technique for the management of bone loss post debridement of infected tibial nonunion. Int Orthop, 2022, 46(9): 1937-1944.
20. 徐永清, 朱跃良, 林玮, 等. 双处截骨纵向搬移治疗长段小腿感染性复合缺损. 生物骨科材料与临床研究, 2018, 15(5): 14-17.
21. Tong K, Zhong Z, Peng Y, et al. Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following posttraumatic osteomyelitis. Injury, 2017, 48(7): 1616-1622.
22. Metaoy S, Rusu I, Pillai A. Adjuvant local antibiotic therapy in the management of diabetic foot osteomyelitis. Clin Diabetes Endocrinol, 2024, 10(1): 51. doi: 10.1186/s40842-024-00200-w.
23. Shen D, Huang K, Guo Q, et al. The efficacy of local antibiotic delivery systems therapy in the management of diabetic foot osteomyelitis: A systematic review and meta-analysis. Int J Low Extrem Wounds, 2024. doi: 10.1177/15347346241266062.

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