Compound fractures of the distal femur pose a significant challenge in management, mainly when a long bone segment is lost. Several management options are available in acute setting, including primary debridement and external fixator application, definitive internal fixation and bone grafting, the Masquelet-induced membrane technique, bone transportation with Ilizarov's ring fixator, or free vascularized fibular grafts [1]. Each of these methods has varying degrees of success and failure. External fixators for the femur have a high risk of pin tract infections and knee stiffness as the knee joint has to be spanned. Ilizarov's technique is effective for managing significant bone defects, but patient compliance can be poor due to the bulky frames and prolonged duration of treatment.

Small defects less than 3–4 cm can be treated effectively with cancellous bone grafts. But large gaps of 6 cm or more are challenging. Allografts can also be used for large defects, but they have a high rate of complications and rejections. Donati et al. reported 35 % nonunion, 16.4 % graft fracture, and 5.4 % infection in their series of 128 patients with massive allografts[2,3]. Using a free vascularized fibular graft as a treatment option for these large defects is technically challenging and requires specialized skills.

The Masquelet-induced membrane technique[4,5] is a newer way of managing large defects in compound fractures of the distal femur with large defects. The process involves placing a cement spacer in the defect to create a biologically active membrane that provides vascularity and growth factors for incorporating bone grafts and prevents absorption. The technique has two stages the mechanical stage, which includes internal fixation and placement of the spacer, and the biological stage after 6–8 weeks, which involves removing the spacer and filling the membrane with a cancellous bone graft. The method has shown promising results in managing these fractures, but it is still evolving.

The gold standard for filling defects in the Masquelet-induced membrane technique is an autologous cancellous bone graft of 1–2 mm in size. Both iliac crests can be used for larger defects requiring substantial bone grafts. If necessary, bone graft substitutes like demineralized or synthetic bone can be incorporated in a 1:3 ratio to supplement the graft. The disadvantage of using only cancellous bone graft is limited weight-bearing on the affected extremity until fracture union. Including a fibula strut and the cancellous bone in the induced membrane enhances structural stability and mechanical strength, enabling early weight-bearing and improving functional outcomes. This study aims to examine the effects of using a non-vascularized fibula as a support combined with a cancellous graft in the Masquelet technique for treating compound fractures of the distal femur. The objective is to determine whether this method improves healing and faster mobilization by providing early mechanical stability.