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Limb salvage in distal tibial osteosarcoma using a custom mega prosthesis

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Abstract

We have assessed the oncological and functional results of limb salvage surgery using a custom-made endoprosthetic replacement in six patients (mean age 17 years) with distal tibial osteosarcoma (stage IIB). A wide margin excision was possible in three, marginal in two and contaminated in one. Skeletal reconstruction was performed using a locally designed and manufactured custom-made distal tibial and ankle replacement prosthesis. Two patients developed local recurrence and one necrosis of the flap and deep infection. In three in whom the prosthesis remained in place the mean functional score according to the rating system of the Musculoskeletal Tumour Society was 24.3/30. In carefully selected patients limb salvage with prosthetic replacement is possible for distal tibial osteosarcomas.

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... The first type of tibial prostheses with an ankle joint was hingerestricted or semi-constrained. [9][10][11][12]14 The main complications were talus collapse, prosthesis loosening, fibula impact, incision necrosis, deep infection, and tumor recurrence. Although these scholars all believed that a tibial prosthesis with an ankle joint can achieve better short-term function with limb reconstruction than with other methods, such as bone transplantation and tumor bone replantation after inactivation, they also emphasized the need for strict selection of cases before opera-tion in view of more complications and poor late outcomes in some cases. ...
... Although these scholars all believed that a tibial prosthesis with an ankle joint can achieve better short-term function with limb reconstruction than with other methods, such as bone transplantation and tumor bone replantation after inactivation, they also emphasized the need for strict selection of cases before opera-tion in view of more complications and poor late outcomes in some cases. [9][10][11][12]14 Another type of prosthesis has no joints. Economopoulos, et al. 13 reported a case of giant cell tumor of the distal tibia that was repaired with porous tantalum metal prosthesis without a joint. ...
... As mentioned above, local stress to a hinged prosthesis will be more intense and complications, such as loosening and talus collapse, will occur more readily. 11,16 There are still complications, such as talus prosthesis loosening, after the use of a semi-constrained artificial ankle. [10][11][12] As in the present case, the distal fibular tumor segment often cannot be retained, and it can be very difficult to reconstruct the peri-ankle ligaments between the metal prosthesis and the host skeleton. ...
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Ameloblastoma in the tibia is rare. Limb reconstruction after tumor resection is challenging in terms of selection of the operative method. Here, we report a case of radical resection of an ameloblastoma in the mid-distal tibia combined with limb salvage using a three-dimensional (3D)-printed prosthesis replacement, with 1-year follow-up results. After receiving local institutional review board approval, a titanium alloy prosthesis was designed using a computer and manufactured with 3D-printing technology. During the operation, the stem of the prosthesis was inserted closely into the proximal tibial medullary cavity. Then, the metal ankle mortise and the talus were compacted closely. Radiographic results at 1-year follow up showed that the prosthesis was well placed, and no loosening was observed. The Musculoskeletal Tumor Society (MSTS) 93 functional score was 26 points, and the functional recovery percentage was 86.7%. Computer-assisted 3D-printing technology allowed for more volume and structural compatibility of the prosthesis, thereby ensuring a smooth operation and initial prosthetic stabilization. During the follow up, the presence of bone ingrowths on the porous surface of some segments of the prosthesis suggested good outcomes for long-term biological integration between the prosthesis and host bone.
... In recent decades, variety of reconstruction methods for bone defect of distal tibia after tumor resection have been explored, including non-biological reconstruction, i.e. prosthetic replacement [7][8][9][10], and biological methods, i.e. autograft (vascularized or non-vascularized fibula [2,4,6,[11][12][13][14][15], recycled tumor-bearing bone [15][16][17]), allograft [3][4][5][6]15,18,19] and distraction osteogenesis [4,20,21]. However, the outcomes of each method are not well known as most studies with a small sample size due to its rarity. ...
... Three studies [3,4,28] of amputation and 33 studies [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][23][24][25][26][27][28][29][30][31][32][33][34][35] of limb salvage were included for comparative analysis. Pooled analysis showed that the mean functional MSTS score of patients received limb salvage tended to be higher than those amputated (77.1% vs 70.9%, P = .055). ...
... Twenty-six studies [2][3][4][5][6][11][12][13][14][15][16][17][18][19][20][21]23,25,26,28,[30][31][32][33][34][35] of biological reconstruction and 9 studies [4,[7][8][9][10]15,24,27,29] of prosthetic replacement were included for comparative analysis. The mean followup durations of biological reconstruction were 67.2 (range, 6-288) and 78.4 (range, 12-324) months for prosthetic replacement, there was no significant difference between these two group (P = .251). ...
Article
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Background Primary malignant or aggressive benign bone tumors rarely occur in distal tibia, and limb salvage remains the mainstay of surgical options. However, reconstruction methods for large bone defect after wide tumor resection in this location are debatable. The purpose of this systematical review is to critically evaluate each reconstruction method regarding the postoperative complications and functional outcome. Methods A systematic review of the 33 studies including 337 cases with tumors affecting distal tibia was performed after searching the PubMed and EMBASE databases. Pooled descriptive statistics with separate analyses for postoperative complications and functional outcome of different reconstruction options were performed. Results 290 (86.1%) patients received limb salvage procedures. Reconstruction strategies including biological reconstruction, such as autograft, allograft, distraction osteogenesis and non-biological prosthetic replacement. The patients received limb salvage procedures tended to have a higher MSTS score (77.1% vs 70.9%, P = .055) and a higher incidence of local relapse (28/290 vs 0/47, P = .052) than those amputated. Biological reconstruction methods provided better functional outcome (78.4% vs 72.2%, P = .017) compared with non-biological prosthetic reconstruction, although similarity of incidence of major complications (51/253 vs 12/37, P = .091). With respect to the comparison between autograft and allograft reconstruction, the autograft seemed to have less major postoperative complications occurrence (27/165 vs 22/78, P = .032), and consequently better functional outcome (MSTS score, 80.2% vs 74.3%, P = .025) than allograft reconstruction. Conclusions Limb salvage results in better functional outcome compared with amputation. Biological reconstruction is more advocated than prosthetics replacement, and furthermore, autograft might be suggested to be the optimal reconstructive method with regard to better postoperative functional outcome and less major complications.
... Учитывая особенности анатомии и биомеханики голеностопного сустава, выполнение реконструктивных операций в данной области всегда сопряжено с большими трудностями. В большинстве случаев применяется артродез или артропластика с использованием модульных или индивидуальных эндопротезов [25,26]. ...
... До недавнего времени оптимальным способом реконструкции являлся артродез голеностопного сустава [27], однако выполнение артродезирования требует длительной иммобилизации, нередко -проведения нескольких операций для достижения консолидации и стабильности голеностопного сустава. В послеоперационном периоде отсутствуют движения в голеностопном суставе, что вызывает функциональные нарушения в суставах среднего и переднего отделов стопы [25,28]. Кроме того, артродез с биологической реконструкцией аутокостью или аллокостью ассоциируется с высоким риском несращения имплантатов с костью, развития переломов, инфекционно-воспалительных осложнений [26]. ...
... Поражение злокачественной или агрессивной доброкачественной опухолью дистального конца большеберцовой кости встречается редко, в связи с чем имеется очень небольшое число работ, посвященных эндопротезированию голеностопного сустава после резекции дистального конца большеберцовой кости, пораженной опухолью [25,26,28,30,31]. Хорошие функциональные результаты были получены после резекции опухоли (двое больных с остеосаркомами, по одному больному с саркомой Юинга, лейомиосаркомой и гигантоклеточной опухолью) и эндопротезирования дистального конца большеберцовой кости у 5 больных, отказавшихся от ампутации [30]. ...
Article
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Case report for the 18 years old female patient with a giant cell tumor of the distal articular end of the right tibia is presented. The surgical intervention included segmental resection of the articular end of the right tibia and substitution of the defect with the custom-made ankle endoprosthesis. The follow up period made up 4 years. The range of motion in the right ankle joint was satisfactory, no relapse occurred and the implant components were stable.
... Первичные опухоли костей редко локализуются в дистальных отделах лучевой и большеберцовой костей на уровне лучезапястного и голеностопного суставов, что объясняет небольшое количество исследований, посвященных этой тематике. Сегментарная резекция кости с эндопротезированием лучезапястного или голеностопного сустава, по мнению ряда авторов, является перспективной методикой, позволяющей добиться хороших онкологических и адекватных функциональных результатов с невысокой частотой развития послеоперационных осложнений [4,[10][11][12][13]. ...
... [4], которые выполнили дистальную резекцию большеберцовой кости с эндопротезированием голеностопного сустава у 6 пациентов с опухолевым поражением этой анатомической зоны, функциональный результат составил 70%. Об аналогичных и сравнимых с нашими функциональных результатах после онкологического эндопротезирования голеностопного сустава сообщают M. Natarajanet (80%) и A. Abudu (81%) [10,11]. При резекции дистального отдела лучевой кости с эндопротезированием лучезапястного сустава H. Hatano и соавт. ...
... Инфицирование металлоимплантата является одним из самых распространенных осложнений при выполнении онкологического эндопротезирования, что может быть обусловлено иммуносупрессией на фоне ранее проведенного системного лекарственного лечения и дефицитом мягких тканей для формирования ложа эндопротеза. Необходимо отметить, что частота развития инфекционных осложнений при эндопротезировании тазобедренного и коленного суставов при опухолевом поражении бедренной и большеберцовой костей может достигать 17-35% [4,[10][11][12]22]. ...
... 15 The local recurrence rate of limb salvage in the distal tibia is variable in each report: 0, 17 12, 16 15, 18 16,19 and 33%. 20 The difference between studies may be attributed to histology, tumor size, and indications for limb salvage in each institution. Nevertheless, the risk of local recurrence after limb salvage surgery without neoadjuvant therapy seems to be higher than that after amputation. ...
... 2,3 In addition, four of five distal tibial cases underwent amputation or disarticulation as an initial surgery. 3,11 In a study on lower limb LGCOS from the United Kingdom, 17 of 18 cases received limb salvage surgery, and their disease-free survival rate was 20,[24][25][26][27] Historically, we had been performing autogenous irradiated bone grafting for the distal tibial lesions of malignant bone tumors. 9,24 In the present case, we devised three strategies to avoid the collapse of the graft such as experienced in the previous osteosarcoma case: (1) filling bone cement to the distal epiphysis and metaphysis of the tibia at surgery, (2) delaying the time of full weight-bearing, (3) attaching a PTB brace to the affected lower leg for a long period of time. ...
... In the article by Shekkeris et al. (12), the mean functional outcome score (MSTS) for the four patients with a surviving endoprosthesis was 70%. Natarajan et al. (13) performed prosthetic replacement of the distal tibia and ankle in six patients, and their mean MSTS score was 80%. Joint reconstructions have more complications than arthrodesis, such as flap complications, loosening of the prosthesis, and fracture of the prosthesis. ...
... Joint reconstructions have more complications than arthrodesis, such as flap complications, loosening of the prosthesis, and fracture of the prosthesis. Moreover, the structural integrity of the involved bone must be maintained (11,(13)(14)(15). ...
Article
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IntroductionFew patients presented with a distal tibial tumor that only invaded a small area of bone in the medial malleolus. There have been no previous cases in which only the medial or lateral malleolus was removed and reconstruction was complete. This article describes our attempt to reconstruct the medial malleolus (1/4 of the ankle joint) after resection of a distal tibial tumor with an uncemented three-dimensional (3D)-printed prosthesis.Case DescriptionA 39-year-old man presented with a lump in the right medial malleolus, and biopsy results suggested fibrosarcoma. To preserve the patient's normal bone and function, we only removed the medial malleolus and reconstructed the ankle joint using a personalized 3D-printed prosthesis. The patient had no complications other than necrosis of the skin flap that covered the wound. The patient recovered well after undergoing an additional skin flap transfer. Follow-up at 7 months and again at 3 years after surgery showed good ankle function and stability, with no pain or complications.Conclusion The 3D-printed partial ankle prosthesis had a good matching degree, strength, and osseointegration ability, but also had a few complications. The patient achieved satisfactory ankle function and stability. However, a longer follow-up period is needed, and more research is required to confirm the efficacy of the prosthesis.
... Although below-knee amputations for distal tibia tumors may provide excellent function with modern prostheses, limb salvage continues to be offered as a standard of care in view of psychological impact and quality of life [8,9]. A variety of procedures have been described in the literature to achieve limb salvage; however, each of them are associated with their inherent problems, namely [7], delay in weight-bearing and graft failures seen with autogenous bone grafting [12,13] as well as fibular autograft and arthrodesis [1,8,10,14]; infection and graft subsidence/lysis concerned with osteoarticular allografts [15][16][17]; distraction osteogenesis [2,14]; and also endoprosthetic reconstruction [3,[18][19][20] failing with infection or inadequate soft tissue coverage. e best option however remains debatable. ...
... Even then, these procedures continue to have high failure rates [5]. Restoration of a functional ankle joint using custom or modular mega-endoprostheses comes with its' inherent complications of loosening or infection [3,[18][19][20]. Distraction osteogenesis is not advocated in the setting of malignant bone tumors requiring adjuvant therapy [2]. ...
Article
Full-text available
Introduction. Traditionally, centralization of the fibula with fusion across the tibiotalar joint has been used to reconstruct distal tibial defects. Although effective, it requires long periods of protected weight-bearing. The fibula or the fixation often fails before fibular hypertrophy necessitating multiple additional surgeries. A method of using ECRT with the available ipsilateral fibula (nonvascularized) to reconstruct the distal tibia defect with the aim of early return to weight-bearing was evolved. This paper documents our early experience. Patients and Methods. Four patients; with the diagnosis of osteosarcoma in 3 patients and recurrent giant cell tumor of the bone in 1 patient, underwent resection of the distal tibia for tumors between 2017 and 2019. Extracorporeally irradiated (50 Gy) distal tibia along with ipsilateral nonvascularized fibula was used to bridge the defect and fuse the tibiotalar joint. A plate was used to rigidly hold the construct. The final outcome was compared to the historical control group that underwent only pedicled ipsilateral fibula transposition and ankle arthrodesis without recycled autograft or allograft between 2009 and 2017. Oncological reconstruction and functional outcomes were compared for each group. Patient reported outcomes on the acceptability of ankle fusion; cosmesis and function were analyzed and compared between the two groups. Results. The mean resection length in the study group (4 patients) was 7.75 cm (7 to 8.5 cm). As compared to the historical cohort of 7 patients, the study population showed statistically superior results in all reconstruction, functional, and patient-reported outcomes except time to proximal junction union (). There were no reconstruction failures, infection, or nonunions in the study group, whereas the control comparative group had 2 proximal junction nonunions and a mean time to fibular hypertrophy of 143 weeks (82 to 430 weeks) with fibula centralization. Earlier weight-bearing was allowed (mean 26.75 weeks; median 27 weeks) compared to (mean 80.75 weeks; median 80 weeks) in the control group. Conclusion. We think that ECRT with ipsilateral vascularized fibula is a promising method of reconstructing the distal tibia. The recycled autograft tibia added strength to the distal tibia construct in our study and aided the anatomical reconstruction of the distal tibia. The patient-reported outcomes for cosmesis and acceptability add to the benefits of performing this procedure. Consistent early union across the proximal junction and earlier weight-bearing were clear advantages of this method. 1. Introduction Distal tibia is an uncommon location for primary malignant tumors of the bone. Most resections include the articular surface, and reconstructions of these defects pose unique challenges including a complex bony anatomy and a thin soft tissue cover. Unlike around the knee or hip, there seems to be no reliable endoprosthetic or biological reconstruction for creating a functional joint at the ankle [1–7]. A below-knee amputation can give excellent functional outcomes and is therefore a suitable alternative to any reconstruction that fuses the tibiotalar joint [8, 9]. The centralization of the fibula (Figures 1(a)–1(c)) into the defect as a vascularized autograft has been used for many years, but the fibula takes a long time to hypertrophy requiring protracted protected weight-bearing (Figure 1(d)) [1, 8, 10]. Additionally, this long period risks breakage of the fixation implants and fractures of the fibula (Figure 1(e)) which many a times require repeated surgical procedures (Figure 1(f)). Inspired from long diaphyseal defect reconstructions, we combined the extracorporeally irradiated tibia after tumor resection with the ipsilateral nonvascularized fibula with an ankle fusion. The extracorporeally irradiated tibia provides the strength till the fibula incorporates, aids union, and gains strength. This paper presents our early results from four such cases. (a)
... econstruction after distal tibial bone loss with ankle involvement remains a therapeutic challenge to orthopaedic surgeons. In order to achieve a stable plantigrade foot without limb-length discrepancy, various methods have been used [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][21][22][23] . Reconstruction with use of a custom-made endoprosthetic ankle implant in tumor patients has had a high complication rate [21][22][23] . ...
... In order to achieve a stable plantigrade foot without limb-length discrepancy, various methods have been used [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][21][22][23] . Reconstruction with use of a custom-made endoprosthetic ankle implant in tumor patients has had a high complication rate [21][22][23] . Problems with deep infection, talar collapse, and deterioration of function over time have limited the use of the technique in this group of patients. ...
... 7 Another study by Natarajan et al. assessed oncological and functional results of limb salvage surgery using custom-made endoprosthetic replacement for distal tibia osteosarcoma. 8 The functional score was 81% but local recurrent and infection were reported (33%) during the follow-up. [8][9][10] These data showed the possibility of prosthetic limb salvage use rather than amputation in spite of some complications. ...
... 8 The functional score was 81% but local recurrent and infection were reported (33%) during the follow-up. [8][9][10] These data showed the possibility of prosthetic limb salvage use rather than amputation in spite of some complications. 9,10 This technique is considered an accessible and economical alternative of high efficiency for reconstructive modalities but did not resolve complications that occurred. ...
Article
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Amputation still considered as primary choice of malignancy treatment in distal tibia. Bone recycling with liquid nitrogen for reconstruction following resection of malignant bone tumours offers many advantages. We presented four patients with osteosarcoma, Ewing sarcoma, adamantinoma and recurrent giant cell tumour over distal tibia. All of the patients underwent wide excision and bone recycling using liquid nitrogen as bone reconstruction. The mean functional Musculoskeletal Tumor Society (MSTS) score was 75% with no infection and local recurrent. The reconstruction provides good local control and functional outcome.
... But in the era of limb salvage, tumours of distal tibia are being dealt with limb salvage surgery to provide patients with a better quality of life [2] . We report a case of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection and reconstruction with custom mega prostheses and ankle arthrodesis [3] Osteosarcomas of the distal tibia are rare. These tumours are usually treated with amputation [2] . ...
... A custom prostheses was designed for the replacement of the resected distal tibial component [3] Due to availability and cost factor stainless steel prostheses was used. The segment resection was 22.5cm from the ankle joint and so base length of 22.5cm and width of 26mm is made with a stem length of 10cm with a proximal width of 10mm tapering to 8mm at the tip. ...
Article
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Distal tibial osteosarcoma: A technique of custom mega prostheses reconstruction Author(s): S Subbiah, G Gopu, Dr. Syed Afroze Hussain and Dr. Bharanidharan Abstract: Primary malignant bone tumours of the distal tibia are very rare. Amputation was the standard surgical treatment with satisfactory functional results obtained using an appropriate prosthesis [1]. But in the era of limb salvage, tumours of distal tibia are being dealt with limb salvage surgery to provide patients with a better quality of life [2]. We report a case of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection and reconstruction with custom mega prostheses and ankle arthrodesis [3] Osteosarcomas of the distal tibia are rare. These tumours are usually treated with amputation [2]. We report a case of osteosarcoma of distal tibia in a 13year old female. The patient presented with complaints of pain and limping gait of 6 months’ duration. Imaging revealed a mixed lesion predominantly sclerotic with moth-eaten appearance, aggressive periosteal reaction in distal tibia. MRI revealed soft tissue involvement. The patient received four cycles of neoadjuvant chemotherapy [4] she had a good clinical response by clinical and imaging evaluation. A distal tibial resection with custom mega prostheses reconstruction was done. The post-operative histopathology revealed an osteoblastic variant of osteosarcoma with 60% of necrosis. The patient completed two more cycles of same chemotherapy [4] the patient was on follow up since four months. The post-treatment functional evaluation was done with “Revised Musculoskeletal Tumour Society Rating Scale [5]. And patient had a score of 26 of 30. The patient was able to walk without crutches DOI: 10.22271/ortho.2017.v3.i1d.38 PDF (320KB) Pages: 233-236 | 55 Views 8 Downloads
... 6 Finally a retrospective analysis by Natarajan et al addressed the need for revision surgery in two of their 6 patients who ultimately had functional scores exceeding 80%. 7 Evidently, we too have less numbers and shorter median follow-up periods. However, we have shown a similarly low rate of local recurrence and complications to existing studies. ...
Article
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Bone tumours around ankle joint are less frequent and literature on them are not abundant, we present our experience
... Dr. Mayilvahanan Natarajan's tireless efforts and groundbreaking contributions to Orthopaedic Oncology were recognized with the Dr. B.C. Roy National Award Through pioneering collaborations between the Cancer Institute (WIA) and the Government General Hospital, Chennai, advanced treatments were made more accessible across the country [11][12][13][14][15]. The tireless advocacy and propagation of these techniques have not only democratized access to orthopaedic oncology care but also positioned India as a leading centre for bone sarcoma treatment globally. ...
... The cosmetic outcome of rotation plasty is a serious disadvantage. [8] ...
... Additionally, because there are no sites for osteosynthesis, prosthetic reconstruction carries a lesser risk of deep infection than allografts, and non-union is not a problem. The longevity, complications, and functional outcome differ depending on the anatomic site, prosthesis type, and fixation method [19,20]. Our study's recommended modality for limb preservation is modular segmental-replacement system prosthesis. ...
Article
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Background The method known as "limb salvage surgery" (LSS) aids in the removal of extremity tumours, and reconstruction is completed with satisfactory oncologic, functional, and cosmetic outcomes. Oncologic clearance is given first priority, followed by functional outcomes. Worldwide, the trend has already shifted away from amputations and toward limb salvage surgery for eligible patients due to efficient chemotherapy regimens, improved imaging techniques, precise administration of enhanced radiation, better reconstructive choices, and developments in bio-engineering. The purpose of the present study was to determine the clinicopathological characteristics, surgical techniques, functional outcome, and prognostic factors of limb salvage surgery performed using mega prosthesis in primary malignant or benign resectable tumours. Methods Our retrospective cohort study was carried out over a period of two years and included 28 patients who received care for bone tumours. The data gathered comprised the demographic profile, clinical characteristics, histological characteristics, treatments given, functional results, and survival. LSS was performed on all patients by orthopaedics oncologists trained in the surgical oncology department. Following surgery, during the first two years, patients were examined at every three-month interval, then every six months until the fifth year, and then once a year after that. The Kaplan-Meier method was utilized to determine the median follow-up and recurrence-free survival (RFS). Results In our study, the mean age of study subjects was 30.0±10.9 years. Almost all of the subjects included in the study had lower limb bone tumours (96.4%). The most common site for the tumour was the distal femur (57.1%) followed by the proximal femur (32.2%). The most common type of benign tumour was giant cell tumour (GCT) (53.6%), including recurrences of giant cell tumour (GCT), and among malignant tumours, osteosarcoma was the most common (25.0%). The mean surgical resection of bone in limb salvage surgery was 125.2±24.2 mm. The most common post-operative complication was leg length discrepancy (LLD) among 25.0% of subjects, which was managed by shoe raise. The overall mean musculoskeletal tumour society (MTSS) score after LSS was 25.0±4.3. Using the Kaplan-Meier method analysis, we found that relapse-free survival was 83.7% among enrolled subjects at a median follow-up period of 80 months. Conclusion It can be difficult to surgically treat patients who have malignant bone tumours. In limb-sparing surgery for bone tumours, the modular segmental-replacement system prosthesis that we preferred produced satisfactory results in terms of tumour control and limb function. To get good long-term results, the case selection must be appropriate.
... Limb-sparing surgery for primary bone tumours of the distal tibia is fraught with difficulties due to the paucity of soft tissue coverage and difficulties in creating a durable fixation of the prosthetic components. 1 Wide surgical margins and acceptable function of the ankle joint can seldom be achieved. 1,2 Therefore, belowknee amputation (BKA) is the surgical method of choice. While oncologically safe, it also provides excellent function with the ever-improving external prosthetics. ...
Article
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BACKGROUND: Below-knee amputation (BKA) is the safest treatment for benign aggressive and malignant bone tumours of the distal tibia, yielding good oncological and functional results. However, in selected patients where limb salvage is feasible and amputation unacceptable to the patient, limb salvage using a distal tibial replacement (DTR) can be considered. This study aims to present the oncological and functional results of the use of the latter treatment method in our unit. METHODS: A retrospective folder review was performed for all ten patients who received a modular DTR between 1 January 2005 and 31 January 2019 for a primary bone tumour, either benign aggressive or malignant. Six were female and the mean age was 31 (12-75) years. There were five patients with giant cell tumour of bone, four with osteosarcoma and one with a low-grade chondrosarcoma. The patients with osteosarcoma had neoadjuvant chemotherapy before surgery. Function was assessed by the Musculoskeletal Tumor Society (MSTS) score. RESULTS: Two patients had local recurrence treated with a BKA and one other patient died of metastases three years postoperatively. At a mean follow-up of three years, the remaining eight patients had a mean MSTS score of 83% (67-93%). There were no radiological signs of loosening, and no revision surgeries. CONCLUSION: Endoprosthetic replacement of the distal tibia for primary bone tumours can be a safe treatment option in very selected cases. Level of evidence: Level 4
... The reconstructive procedure to bridge the bone gaps depends on-the durability of the procedure, the oncological prognosis, restoration of anatomy and functional needs of the patient. 7 Reconstruction methods include osteoarticular allografts, allograft prosthetic composites and segmental endoprosthesis replacement. 8,9 Rotationplasty gives excellent functional results but it is not cosmetically acceptable to many. 10 Resection arthrodesis achieves excellent stability but renders the joint rigid and immobile. ...
Article
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Background: Juxta articular giant cell tumors around the knee constitute 50-60% of the total cases reported. If the disease is detected at an advanced stage, reconstruction of the joint after tumor excision poses problems and has poor functional outcome. The aim of the study was to determine the functional outcome after resection of juxta-articular giant cell tumors around the knee and its reconstruction with mega prosthetic arthroplasty will be analyzed.Methods: Between January 2017 and March 2021, 14 patients in the age group of 28-48 years (mean=42.85 years) with Campanacci stage three giant cell tumors around the knee were studied (12-distal femur patients, 2-proximal tibia). Patients underwent tumor excision and reconstruction with modular megaprosthesis. They were evaluated post-operatively using the Revised Musculoskeletal Tumor Society Score (MSTS) for lower limb. Results: All the patients were followed up for 12-44 months (mean=29.5 months), the average knee flexion at 6 months being 116.4 degrees. The mean MSTS at 6, 12, 18 and 24 months are 19.45, 23.23, 26.61 and 28.77 respectively. Complications observed were infection and tumor recurrence. Conclusions: In advanced cases where tumor excision leaves large bone segment loss, reconstruction with megaprosthesis can give desirable functional outcome.
... Megaendoprostheses are a wellestablished and accepted reconstruction technique of osteoarticular defects of the hip, knee, and glenohumeral joint [1]. However, depending on the amount of remaining bone stock and soft tissue coverage, standard megaendoprosthetic implants are either unavailable or associated with higher complication rates in more distally located sites such as the distal tibia and ankle [2][3][4][5][6][7]. Since three-dimensional (3D) computer-assisted design (3D-CAD) and 3D-printing technology were introduced in the production process of orthopedic implants, the availability of patient-individualized stems and anatomy-imitating implants in complex anatomic and biomechanical sites has improved the rates of joint and limb salvage of both osteoarticular and intercalary reconstructions [8][9][10]. ...
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Custom-made, three-dimensionally-printed (3D) bone prostheses gain increasing importance in the reconstruction of bone defects after musculoskeletal tumor resections. They may allow preservation of little remaining bone stock and ensure joint or limb salvage. However, we believe that by constructing anatomy-imitating implants with highly cancellous titanium alloy (TiAl6V4) surfaces using 3D printing technology, further benefits such as functional enhancement and reduction of complications may be achieved. We present a case series of four patients reconstructed using custom-made, 3D-printed intercalary monobloc tibia prostheses treated between 2016 and 2020. The mean patient age at operation was 30 years. Tumor resections were performed for Ewing sarcoma (n = 2), high-grade undifferentiated pleomorphic bone sarcoma (n = 1) and adamantinoma (n = 1). Mean resection length was 17.5 cm and mean operation time 147 min. All patients achieved full weight-bearing and limb salvage at a mean follow-up of 21.25 months. One patient developed a non-union at the proximal bone-implant interface. Alteration of implant design prevented non-union in later patients. Mean MSTS and TESS scores were 23.5 and 88. 3D-printed, custom-made intercalary tibia prostheses achieved joint and limb salvage in this case series despite high, published complication rates for biological and endoprosthetic reconstructions of the diaphyseal and distal tibia. Ingrowth of soft tissues into the highly cancellous implant surface structure reduces dead space, enhances function, and appears promising in reducing complication rates.
... The mean MSTS score was 69.95 in our study which concurs with world literature. [48][49][50] Strengths and limitations of the study About 95.1% of our patients completed the prescribed treatment and we have 82.9% follow-up. We have long-term follow-up, and data have been well maintained. ...
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Background: Limb salvage surgery (LSS) is the current surgical standard for malignant bone tumors. The advancements in imaging, surgical techniques, chemotherapy, and biomedical engineering have made LSS oncologically safe and with improved functional outcome. In this retrospective study, we report our experience with LSS and perioperative chemotherapy for osteosarcoma in a tertiary cancer center in India. Materials and Methods: A total of 41 LSS were performed from January 2009 to January 2015. Perioperative chemotherapy was administered to all patients after histopathological confirmation of osteosarcoma. The functional outcome of the patients was evaluated using the musculoskeletal tumor society (MSTS) scoring system at regular intervals. Statistical analysis involved the use of descriptive and inferential statistics for data analysis. Kaplan–Meier method was used for calculating the recurrence free and overall survival (OS) and log-rank test for comparing survival functions. Spearman and Karl Pearson's methods were used for correlation analysis. Results: The mean age was 19.3 years (range, 8–49 years). Twenty-five (61%) patients were males. Thirty-six (88%) patients had conventional high-grade osteosarcoma. Five-year relapse-free survival and OS were 56.1% ± 7.8% (95% confidence interval [CI], 53.7–58.5) and 58.5% ± 7.7% (95% CI, 56.1–60.9), respectively. The mean MSTS scores at 1 year for tumors of the upper tibia and distal femur were 64 and 75.9, respectively. Patients with high rate of chemotherapy-induced tumor necrosis (>99%) had significantly better median OS (85.70 ± 8.22 months) compared to those with less (
... In the past decades, below-knee (B-K) ablation was the standard treatment for malignant bone tumors and for local recurrences of aggressive bone tumors of distal tibia [4]. Nowadays, advanced chemotherapy and surgical techniques made limb salvage possible, and previous studies have proved that limb salvage can achieve acceptable functional outcome and survival rates compared with ablative technique [5][6][7][8][9][10][11][12][13]. Various reconstruction options have been reported in literature, including massive allograft, recycled tumor-bearing bone, vascularized or non-vascularized autografts, prosthetic replacement or bone transport [7,8,12,[14][15][16][17][18][19][20][21]. ...
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Background: Reconstruction for large bone defect of distal tibia after wide resection of tumor is difficult, and the best option remains controversial. This study presents a novel "double-strut" fibula ankle arthrodesis for this issue. Methods: Nine patients with malignant or aggressive tumors of distal tibia underwent novel "double-strut" fibula ankle arthrodesis after wide tumor resection were retrospectively reviewed. We assessed the bone union time, complications and oncology outcome clinically and radiographically. The Musculoskeletal Tumor Society (MSTS) score and the Foot and Ankle Outcome Score (FAOS) were used to evaluate the functional outcome. Results: The average followup period was 53 ± 46 months. There was no deep infection or graft fracture observed in this series. Internal fixation loosening was found in one case. In these patients, eight achieved union at both proximal and distal junctions, while one achieved union only distally. The mean union time of the proximal junctions and distal junctions was 10.5 ± 1.6 months and 8.7 ± 2.3 months, respectively. The mean postoperative MSTS score was 83% ± 8%. The subscales of FAOS indicating the most problem was Sport and Recreation Function with a mean score of 18 ± 11. At the final follow-up, one of them (1/9, 11%) experienced local recurrence in soft tissue and received another resection surgery, and four (4/9, 44%) patients developed lung metastases. Conclusions: For large bone defect of distal tibia, this novel "double-strut" fibula reconstruction can be a viable alternative, which is capable of achieving durable ankle fusion and functional salvaged limb with low rate of complications.
... These complications had negative impact on quality of life, gait disturbances, pain sensations, and poor mental condition of patients. Revision surgeries were burdened with a high risk of side effects and made it difficult to proceed with oncological treatment [1][2][3][4]. ...
... Clinical treatment experience is also limited due to the low incidence of tibial tumors. 1 Reconstruction methods such as tumor-type prostheses or allogeneic bone grafts are often associated with complications including infection and instability. 2,3 Fibular surgery using vascular pedicles requires complex microsurgical skills and achieves poor mechanical stabili- ty. 4 Bone transport has been widely used to treat large segmental bone defects after traumatic surgery. 5 This technique is less risky and is associated with fewer postoper- ative complications and better long-term outcomes after the biological reconstruc- tion has healed. ...
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This study was performed to explore the clinical efficacy of bone transport using external fixation for treatment of large bone defects after tibial tumor resection in five patients. Bone transport started 14 days postoperatively at 1 mm/day and was adjusted according to the callus-to-diameter ratio. The bone transport time, bone graft fusion, relapse, and metastasis were recorded. Clinical efficacy was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system. The tumors included osteosarcoma (n=2), Ewing sarcoma (n=1), malignant schwannoma (n=1), and hemangioma (n=1). The average bone defect length after resection was 11.6 cm. The five patients were followed up for an average of 50.8 months, and the average bone transport time was 15.5 months. Three patients who underwent postoperative chemotherapy were followed for 22.7 months, and two who did not undergo chemotherapy were followed for 4.75 months. Four patients underwent iliac bone grafting, and one underwent vascular pedicle fibular transplantation. The average MSTS score was 21.2 (19.3 for patients who underwent chemotherapy and 24.0 for patients who did not). No relapse or metastasis was observed. Bone transport is effective for reconstruction of large bone defects after tibial tumor resection as well as tibial malignancies with high doses of chemotherapy.
... Endoprosthetic reconstruction [26,27] is not suitable for the CPGDs. Megaprosthesis [28] for these kinds of defects are associated with unacceptable complications. The age-old Van Nes Rotation plasty and its modifications Borggreve [29] rotation plasty are rarely adopted in modern practice. ...
Article
Introduction: Composite perigenual defects (CPGDs) are exacting the expertise of the reconstructive surgeons. Segmental skeletal defects continue to be a challenge for both orthopedic and plastic surgeons. There are many techniques available for the reconstruction of segmental skeletal defects in the perigenual region. This study explores the outcomes of pedicled chimeric propelled osteomyocutaneous fibula flap reconstruction of post traumatic and post excisional composite perigenual defects (CPGDs) MATERIALS AND METHODS: It was a retrospective study conducted from 2011 to 2016 including 16 patients (5 post excisional defects and 11 post traumatic defects). 14 males and 2 females were included. Ages of the patients were ranging from 24 to 46 years. All had their CPGDs reconstructed with chimeric pedicled propelled fibula osteomyocutaneous flap RESULTS: All 15 patients on an average of 26 months follow-up assumed pain free unrestrictive walking. Fracture of hardware and transferred fibula occurred in one case 2 1/2 years following the surgery. Other patients had good functional recovery in an average of 26 months follow up. The average MSTS score of 15 patients was 23.9. Conclusion: This anatomically construed procedure will be addendum to the armamentarium of reconstruction in both post excisional limb salvage milieu and secondary posttraumatic context for the perigenual composite defects. With high healing potential, infection culling capacity, high osteogenic potential and good supportive hardwares the pedicled osteomyocutaneous fibula flap may usher in better outcome in composite perigenual defects reconstruction.
... Due to the inherent lack of soft tissue envelope surrounding the ankle and the relatively poor vascularity, wound dehiscence and deep infection do not seldom occur when limb salvage surgery is performed to treat aggressive tumour involving the distal tibia [26]. However, none of these complications occurred in our cases. ...
Article
PurposeWe report the oncological and functional results of limb salvage for bone sarcomas involving the distal tibia using hybrid surgical technique of resection arthrodesis by bone transport then plating. Methods Five patients (mean age 18.6 years) with primary distal tibial sarcomas (two Ewing’s sarcomas and three osteosarcomas) were treated by this method. The average duration of follow-up is 53 months. All patients accepted distraction osteogenesis with a standard technique using external fixator after wide (four cases) or marginal (one case) resection in the first operation. They were re-admitted for the second surgical treatment (plate insertion and removal of the external fixator) one to two months after they achieved the necessary limb length and desired alignment. ResultsSolid union of the lengthening site and sound fusion of the ankle were achieved in all five patients with full and unassisted weight bearing. The mean lengthening was 11.8 cm (range 8–14 cm) and the external fixation index (EFI) was 29.3 days/cm (range 22.8–36.3 days/cm). The mean functional score according to the rating system of the Musculoskeletal Tumour Society was 88% (83–90%). One patient showed poor response to chemotherapy, had local recurrence of sarcoma one year after plating, and was treated with above-knee amputation. Conclusions In carefully selected patients with primary distal tibial sarcomas, this hybrid method can effectively eliminate tumor lesion, reconstruct function, and shorten the length of wearing an external fixator by a meticulous conversion to internal fixator.
... The ideal reconstruction of the defect created after en block resection of the tumor is still debated. Endoprosthetic replacement incurs a high financial cost and involves many complications including a 12% deep infection rate, loosening, breakage, a 70% probability of further surgical procedures being required within ten years and an amputation risk of 25%, as reported in some studies (17)(18)(19) . Massive allografts are widely used in many centres. ...
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... The ideal reconstruction of the defect created after en block resection of the tumor is still debated. Endoprosthetic replacement incurs a high financial cost and involves many complications including a 12% deep infection rate, loosening, breakage, a 70% probability of further surgical procedures being required within ten years and an amputation risk of 25%, as reported in some studies (17)(18)(19) . Massive allografts are widely used in many centres. ...
Article
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Background: Reconstruction after en block resection of malignant tumors is still the subject of debate. We questioned the effectiveness of reconstruction by reimplanting the diaphyseal tumor bearing segment after recycling in liquid nitrogen in cases of Ewing sarcoma. Patients and Methods: Eight patients with Ewing sarcoma around the knee were included, with a mean age of 14.5 years. The operative technique included wide en bloc excision, debridement, and management of the resected segment with liquid nitrogen followed by reimplantation and internal fixation. Results: At a mean follow-up of 21.5 months there was no local or systemic recurrence and the mean functional score was 80.6%. The frozen graft united proximally and distally in all in a period ranging from six to nine months. No major complications were reported. Conclusion: The effectiveness of this reconstruction technique in properly selected patients with Ewing sarcoma is comparable to other techniques of biological reconstruction with the added benefit of being simple, cheap and durable.
... Tumor prostheses provide advantages, such as convenience, rapid mobilization and weight bearing capabilities (13). However, tumor prostheses incur a high financial cost and involve various complications, including infection, aseptic loosening, breakage during the long-term follow-up and a higher probability of revision surgery being required within 10 years, as reported in some studies (13)(14)(15). Allografts are a common reconstructive method utilized in some western countries, whereas this technique is forbidden in some Asian and African countries due to religious reasons (16). Although it is a biological reconstructive method, it carries a high risk of transmission of infectious diseases, fracture, tissue rejection, articular cartilage degeneration and poor union rate (3). ...
Article
Reconstruction of the defect following limb-sparing resection of malignant bone tumors is controversial and extremely challenging. Extracorporeal irradiation (ECI) and re-implantation have been used for limb salvage surgery for patients, with major advantages, including biological reconstruction, ready availability and preservation of bone stock, over replacement with a megaprosthesis. The purpose of the present study was to present our experience and details of all patients treated with this surgery. Between June 2005 and December 2014, we followed-up 23 patients with limb malignancies who were treated with en bloc excision followed by 50-Gy single dose ECI and re-implantation of involved bone segments. All cases were evaluated based on clinical and radiological examinations, complications and Musculoskeletal Tumor Society (MSTS) score. Mean follow-up period was 77.6 months (range, 17-116 months). A total of 17 patients (73.9%) demonstrated no evidence of disease, 5 (21.7%) patients succumbed to the disease and 1 (4.3%) patient was alive with the disease at the final follow-up. Local recurrence occurred in 3 patients (recurrence rate, 13.0%) in the bed outside of the irradiated graft, and 4 of the 5 patients that lost their lives did so due to associated metastatic disease. The mean value of the MSTS score was 78.8% (50-93.3%). The majority of patients demonstrated solid bony union; however, 3 patients had non-union (13.0%) and 1 had a delayed union (4.3%). Early or late complications occurred in 11 patients (47.8%). Although the complication rate (47.8%) and re-operation rate (39.1%) were high, ECI and re-implantation may be a useful and cheap technique following en bloc resection for limb salvage in appropriately selected patients.
... 101 At 40 months follow-up of six comparable patients, three were converted to amputation (two local recurrence, one deep infection), with the remaining three able to function pain free with a stable prosthesis. 102 ...
Article
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Total ankle arthroplasty is a treatment option for end-stage osteoarthritis of the ankle, as is ankle arthrodesis. Many variables, including patient characteristics, are thought to influence clinical outcome and survival. As with any surgery, but especially with total ankle replacement (TAR), patient selection is considered critical for good (long-term) outcome. In this review, we summarize the available scientific evidence regarding patient characteristics and its influence on the results of TAR.
... An arthrodesed knee is awkward and causes problems when sitting, particularly in public transport such as buses, trains etc., The cosmetic outcome of rotation plasty is a serious disadvantage. [7,8] Hence, custom mega prosthetic arthroplasty has become the method of choice after bone tumor resection at the hip and knee. It is the primary modality in the treatment of aggressive bone tumors of lower limb. ...
Article
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Introduction: Giant cell tumor (GCT) also called osteoclastoma of bone is the most common osteolytic bone tumor encountered by an orthopedic surgeon. En bloc resection of major joints creates a problem for the reconstruction of large defects. Recent advances in tumor resection defects involve the use of custom-built joints for the reconstruction of defects near joints. This article analyzes the functional outcomes after resection of juxta articular GCTs and reconstruction by custom mega prosthetic arthroplasty. Aims and Objectives: To study the functional results of custom mega prosthetic reconstruction in juxta articular GCTs with intra articular extension. Materials and Methods: Four patients with juxta articular GCTs around the hip and knee with mean age of 40 yrs (range 30 to 50 yrs) underwent resection and reconstruction by custom mega prosthetic arthroplasty during the period 2011 to 2013. Two patients were males and two were females. All of them were in Enneking stage 3. Proximal femur was involved in one patient, distal femur in one and proximal tibia in two patients. Results: Functional results were analyzed using Ennekings criteria. Excellent results were obtained in all the patients without recurrence, periprosthetic fractures, infections or aseptic loosening. Conclusion: By using the technique of custom mega prosthetic reconstruction in juxta articular GCTs with pathological fractures or intra articular extension, the desired goals of reconstruction with good functional results and least complications can be achieved.
... Though osteosarcomas at the distal tibia are rare (< 4% of all osteosarcomas), several forms of reconstruction have been described, and there are problems with each. Prosthetic reconstruction is associated with frequent complications [1,9,14], and allografts have high rates of nonunions and delayed unions [2,13]. Vascularized fibular autografts (either pedicled or free) are technically demanding, lengthy procedures associated with a protracted convalescence during which weight bearing is limited [4,8,15,16]. ...
... The tibia is the second most-common site of osteosarcoma, accounting for 19% of all osteosarcomas, with 20% of those occurring in the distal tibia [22]. Amputation has long been regarded as the standard surgical treatment for these tumors, with satisfactory functional results when an appropriate prosthesis is used [25]. ...
Article
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Background Amputation has been the standard surgical treatment for distal tibia osteosarcoma owing to its unique anatomic features. Preliminary research suggested that microwave-induced hyperthermia may have a role in treating osteosarcoma in some locations of the body (such as the pelvis), but to our knowledge, no comparative study has evaluated its efficacy in a difficult-to-treat location like the distal tibia. QuestionsDoes microwave-induced hyperthermia result in (1) improved survival, (2) decreased local recurrence, (3) improved Musculoskeletal Tumor Society (MSTS) scores, or (4) fewer complications than amputation in patients with a distal tibial osteosarcoma? Methods Between 2000 and 2015, we treated 79 patients for a distal tibia osteosarcoma without metastases. Of those, 52 were treated with microwave-induced hyperthermia, and 27 with amputation. Patients were considered eligible for microwave-induced hyperthermia if they had an at least 20-mm available distance from the tumor edge to the articular surface, good clinical and imaging response to neoadjuvant chemotherapy, and no pathologic fracture. Patients not meeting these indications were treated with amputation. In addition, if neither the posterior tibial artery nor the dorsalis pedis artery was salvageable, the patients were treated with amputation and were not included in any group in this study. A total of 13 other patients were treated with conventional limb-salvage resections and reconstructions (at the request of the patient, based on patient preference) and were not included in this study. All 79 patients in this retrospective study were available for followup at a minimum of 12 months (mean followup in the hyperthermia group, 79 months, range 12–158 months; mean followup in the amputation group, 95 months, range, 15–142 months). With the numbers available, the groups were no different in terms of sex, age, tumor grade, tumor stage, or tumor size. All statistical tests were two-sided, and a probability less than 0.05 was considered statistically significant. Survival to death was evaluated using Kaplan-Meier analysis. Complications were recorded from the patients’ files and graded using the classification of surgical complications described by Dindo et al. ResultsIn the limb-salvage group, Kaplan Meier survival at 6 years was 80% (95% CI, 63%–90%), and this was not different with the numbers available from survivorship in the amputation group at 6 years (70%; 95% CI, 37%–90%; p = 0.301).With the numbers available, we found no difference in local recurrence (six versus 0; p = 0.066). However mean ± SD MSTS functional scores were higher in patients who had microwave-induced hyperthermia compared with those who had amputations (85% ± 6% versus 66% ± 5%; p = 0.008).With the numbers available, we found no difference in the proportion of patients experiencing complications between the two groups (six of 52 [12%] versus three of 27 [11%]; p = 0.954). Conclusions We were encouraged to find no early differences in survival, local recurrence, or serious complications between microwave-induced hyperthermia and amputation, and a functional advantage in favor of microwave-induced hyperthermia. However, these findings should be replicated in larger studies with longer mean duration of followup, and in studies that compare microwave-induced hyperthermia with conventional limb-sparing approaches. Level of EvidenceLevel III, therapeutic study.
... Although it is the treatment of choice for these tumors, wide resection creates a problem for the reconstruction of large bone gaps. The reconstructive procedure has to be based on several considerations, such as durability of the surgical procedure, the oncological prognosis, restoration of the anatomy and function, and the needs of the patient [25] . Rotationplasty gives excellent functional results but the cosmetic outcome is a serious disadvantage of this procedure [26] . ...
Article
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A case report of resection arthroplasty for Giant cell tumor of distal femur with megaprosthesis Author(s): Dr. Eknath D Pawar, Dr. Hitesh Mangukiya, Dr. Neetin P Mahajan, Dr. Ayush Kumar Singh and Dr. Ujwal Ramteke Abstract: Giant cell tumors (GCT) are neoplasms of mesenchymal stromal cells with varied manifestations. Giant cell tumor is considered to be of benign nature but 3% of giant cell tumors are primarily malignant or will undergo malignant transformation and metastasize. The World Health Organisation has classified GCT as "an aggressive, potentially malignant lesion", which means that its evolution based on its histological features is unpredictable. Although there are studies available mentioning various treatment modalities, their advantages and disadvantages, definitive criteria were not laid down regarding treatment. We consider worthwhile reporting a case of distal femoral aggressive GCT treated by enbloc excision and reconstruction with custom mega prosthesis with good functional outcome. DOI: 10.22271/ortho.2016.v2.i4g.71 PDF (479KB) Pages: 463-467 | 12 Views 5 Downloads
... Currently, several options are available for limb reconstruction following the resection of malignant tumors, including tumor prostheses, allografts, and vascularized, autologous osseous grafts. However, reconstruction of large tibial bone defects resulting from the resection of osteosarcomas remains challenging (4)(5)(6). Bone transport distraction osteogenesis is widely used in the reconstruction of large bone defects following trauma, but its use has rarely been reported in defects resulting from the removal of bone tumors (7). This is primarily due to concerns regarding the possible detrimental effects of chemotherapy administered for osteosarcoma on bone transport osteogenesis and bone union. ...
Article
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The clinical efficiency of bone transport distraction osteogenesis in the reconstruction of large tibial defects following resection of osteosarcoma remains unclear. The current study presents two cases of large tibial defects treated with bone transport distraction using an Orthofix external fixator. Case 1 was a 29-year-old man with a tibial defect 11 cm in length, while case 2 was a 16-year-old girl with a 15-cm-long defect. Bone transport distraction osteogenesis was initiated for the both cases on day 14 following resection of the tibial osteosarcoma. Bone transport distraction in case 1 and 2 was continued for 16 and 28 months, respectively, and the patients were followed up for 51 and 56 months, respectively. The two patients did not exhibit any signs of tumor recurrence or tumor metastasis during the follow-up period. The Musculoskeletal Tumor Society functional scores at final follow-up visits were 22 and 18 for case 1 and 2, respectively. Based on the experience gained in these 2 cases, a bone transport is a viable option for the reconstruction of large tibial defects following osteosarcoma resection.
... Recently, social reasons and improved technique have made limb salvage in the distal tibia increasingly possible [7]. Among the many options of reconstruction, ankle endoprosthetic is not accepted by most surgeons because of its high rate of complications [8]. Arthrodesis was preferred, providing excellent stability of the ankle and avoiding problem relating to prosthetic implantation. ...
Article
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Background: Aggressive chondroblastoma of the distal tibia is rare, and below-knee amputation had been the standard surgical procedure. Case presentation: We reported an additional case and reviewed the existing literature. A 20-year-old man with a 2-month history of right ankle pain and swelling underwent distal tibia wide resection, double pedicle fibular, autogenous iliac bone graft, and ankle arthrodesis. He had no pain, no limitation in daily activities, and no evidence of local recurrence and infection; the Musculoskeletal Tumour Society Score (MSTS) is 86 % at the final follow-up. Conclusions: Double pedicel fibular graft and ankle arthrodesis may be an effective and economical alternative method for aggressive chondroblastoma in the distal tibia.
... The cosmetic outcome of rotation plasty is a serious disadvantage. [7,8] Hence, custom mega prosthetic arthroplasty has become the method of choice after bone tumor resection at the knee. It is the primary modality in the treatment of aggressive bone tumors of lower limb. ...
Article
Full-text available
Giant cell tumor (GCT) also called osteoclastoma of bone is the most common bone tumor encountered by an orthopedic surgeon. GCT generally occurs in skeletally mature individuals with peak incidence in the third decade of life. Less than 5% are found in patients with open physis and only about 10% of cases occur in patients older than 65 years. We present a case of distal femoral GCT managed with custom mega prosthetic arthroplasty.
... Progress in biomedical engineering along with better surgical techniques has improved overall 10-year prosthetic survival rate after endoprosthetic replacement from 20% to 80% in the past three decades. [7][8][9] Here we present our experience with long stem prosthetic arthroplasty with mesh for juxta articular giant cell tumors around the knee. Use of mesh in our series has proved to be a good option for reconstruction of juxta articular bone gaps during arthroplasty. ...
Article
Background Reconstruction after en bloc resection of the distal tibia has remained an unsettled issue despite many attempts with bone grafts or prostheses in the past. Failures of the previous methods have been attributed to inadequate mechanical strength, poor articular stability, failed osseointegration, and poor soft tissue coverage. To overcome these shortcomings, we designed and applied a 3D-printed megaprosthesis with ankle arthrodesis. Patients and Methods A total of 13 patients underwent resection of a distal tibial tumor and reconstruction with a 3D-printed distal tibial megaprosthesis between January 2017 and November 2020. Mean age was 14.9±6.5 years. Diagnoses included 11 cases of osteosarcoma and 1 case each of low-grade phosphaturic mesenchymal tumor and rhabdomyosarcoma. Baseline characteristics, operative data, complication profiles, and oncologic, and functional outcomes were reviewed and analyzed. Results All 13 cases attained a wide or marginal resection. During a mean follow-up of 26.8±10.6 months, 1 patient experienced local recurrence and distant metastasis, whereas 3 other patients only developed distant metastasis. Periprosthetic infection subsequent to paronychia occurred in 1 patient 24 months after the operation. No other complications were observed. By the last follow-up, the mean MSTS-93 score was 28.0±1.5. Conclusion In this relatively small cohort with short-term follow-up, reconstruction with the 3D-printed megaprosthesis with ankle arthrodesis was found to be a safe and efficacious method after resection of a distal tibial malignancy.
Article
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Below-knee amputation is the treatment of choice for distal tibia malignancies, considering the specific anatomic features of the distal leg and ankle. However, advances in imaging modalities and adjuvant therapies and improved surgical techniques have made limb salvage surgery increasingly possible. The distal tibia is an uncommon location for malignant bone tumors, and there is limited information about limb salvage and reconstruction. Currently, 3-dimensional printed implants may successfully address reconstruction challenges after tumor resection. We present a patient with high-grade osteosarcoma of the distal tibia who underwent limb salvage and distal tibia and ankle joint replacement with a 3-dimensional printed endoprosthesis. [Orthopedics. 20XX;XX(X):xx-xx.].
Article
Introdaction. In the general structure of oncological endoprosthetics, primary lesions of the distal tibia are rarely affected. Endoprosthetics of the ankle joint region are associated with characteristic difficulties consisting in soft tissue deficiency and restoration of the biomechanics of the lost joint. The existing scientific volume of the literature data on primary ankle replacement is insignificant. At the moment, there is no experience and clear strategy in revision endoprosthetics of this area, complications remain insufficiently explored. Objective. The aim of the study was a discrete analysis of medium- and long-term results, the structure of complications, and functional results in a group of patients after primary and repeated oncological ankle replacement. Materials and methods. The study included 20 patients with benign and malignant bone tumors, who from July 2008 to November 2019 underwent 33 primary and revision replacements in case of distal tibia tumor lesion. In the study group of patients, 70 % were diagnosed with a primary malignant tumor and 30 % had a benign lesion of the tibia. The mean follow-up period was 58,6 months. Results. The leading complication after primary and revision endoprosthetics was early aseptic instability (type IIA) – 20,0 and 23,1 %, respectively. Primary and revision endoprosthetics survival after 5 years was 40,1 ± 12 %. Conclusion. The average functional result after primary and revision ankle replacement was evaluated according to the MSTS scale and after 6 months was 70,5 % and varied from 40 to 87 %. After 12 months, this figure was 76 % and ranged from 46,7 to 96,7 %. The choice of an endoprosthesis, taking into account the optimal biomechanics design of the endoprosthesis unit, methods of fixation, the introduction of innovative technological solutions in the design, materials of the endoprosthesis, adherence to the principle of radicalism will become a means of reducing the frequency of complications.
Article
Osteofibrous dysplasia is an indolent benign fibro-osseous tumor, while adamantinoma is a locally aggressive biphasic malignancy with epithelial and fibro-osseous components. Predominantly arising in the tibial diaphysis of children and young adults, both tumors are resistant to chemotherapy and radiation. Wide surgical resection is regarded as the mainstay of therapy for both malignancies, and limb-salvage reconstructive procedures can achieve good functional outcomes, albeit with non-negligible rates of complications. The present review discusses emerging advances in the pathogenesis, histogenesis, and diagnosis of these entities and presents advantages and limitations of the most common surgical techniques used for their management.
Article
Background Joint reconstruction following resection of malignant bone tumors is challenging in itself in spite of several options in hand. Ability to restore joint anatomy, function and mobility while achieving optimal oncological outcomes are the requirement of reconstructions today. While biological reconstructions (allograft or recycled tumor autografts) following tumor bone surgery are popular for intercalary resections not involving the joint, their use for osteo-articular reconstructions are associated with concerns over cartilage and joint health. We have used extracorporeal radiation therapy (ECRT) and re-implantation of the osteoarticular segment as a size matched recycled tumor autograft reconstruction after complex acetabular and proximal ulnar resections; owing to the lack of significantly superior reconstruction alternatives in these locations and also review the current literature on other biological/non-biological reconstruction options. Questions/purposes (1) What are the oncological, reconstruction and functional outcomes with osteo-articular reconstruction using ECRT and re-implantation of recycled tumor autograft for the acetabulum and olecranon? (2) Is there an evidence of cartilage loss, joint damage or avascular necrosis resulting from irradiation of the articular autograft? Methods 19 patients with primary bone tumors underwent limb salvage surgery with en-bloc resection and reconstruction using the resected articular tumor bone after treating it with extra-corporeal irradiation of 50–60Gy. These included 16 acetabular and 3 proximal ulnar. While all patients were included for oncological assessment; minimum follow-up of 24 months was considered for final outcome assessment of function and joint status. Results MSTS scores of the 16 acetabular reconstruction patients with minimum 2 years follow-up was 87% (26/30). Neither delayed union, non-union at osteotomy sites nor was any fractures reported in the irradiated graft. There was no local recurrence within the irradiated graft and only 1 patient required graft excision for uncontrolled infection. All 3 patients of proximal ulna reconstruction achieved healing and full range of movement of the elbow. Scores of MSTS: 100% (30/30), MEPS: 100 and DASH: zero was achieved. Two patients developed osteonecrosis of the femoral head; one requiring a joint replacement and one awaiting replacement. One patient of acetabular reconstruction has joint space narrowing on radiographs with mild clinical symptoms. Conclusions Extracorporeal radiotherapy and re-implantation after osteo-articular resection is an oncologically safe option offering promising outcome in our small series. The availability of size-matched graft, thus avoiding inherent problems of allograft also provides a better economic option over endoprosthesis and its associated complications in select sites. The results can deteriorate over time that may require secondary reconstructive procedures like joint replacement. Level of evidence Level IV, Therapeutic Study.
Article
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Case report for the 18 years old female patient with a giant cell tumor of the distal articular end of the right tibia is presented. The surgical intervention included segmental resection of the articular end of the right tibia and substitution of the defect with the custom-made ankle endoprosthesis. The follow up period made up 4 years. The range of motion in the right ankle joint was satisfactory, no relapse occurred and the implant components were stable.
Article
Background: Many reconstruction methods have evolved to offer limb salvage surgery (LSS) to patients with musculoskeletal sarcomas. It can be achieved using endoprosthesis or biological reconstruction methods like allograft or autograft or a combination of both. In carefully selected patients, resected bone can be recycled and reimplanted after sterilisation using methods like irradiation, autoclaving, pasteurisation or liquid nitrogen. Methods: From 2010 to 2016, 10 patients with primary musculoskeletal sarcoma underwent limb salvage surgery (LSS) by wide resection of the tumour and reconstruction using recycled autograft treated with liquid nitrogen. Intercalary resection was carried out in six patients and intra-articular in four. The resected bone was dipped in liquid nitrogen for 25 min, thawed at room temperature for 15 min followed by dipping in vancomycin-mixed saline for 10 min. The recycled bone was re-implanted into its original site and stabilised with internal fixation. Results: At a mean follow-up period of 39.6 months (range 6-97 months), all patients had a good function (mean functional score of 80%) with no evidence of local recurrence in the re-implanted bone or otherwise. Union was achieved at 15 of the 16 osteotomy sites with a mean union time of 5.2 months (range 4-7 months) without any additional surgical interventions. In none of the patient, augmentation with vascularised/non-vascularised fibula was done. No complication like fracture of the autograft, implant failure or deep/superficial infection was reported in any patient. Conclusion: Recycled tumour-bearing autograft after treatment with liquid nitrogen is an anatomical, cost-effective, relatively simpler and reliable technique for reconstruction of bone defect after resection in selective primary musculoskeletal sarcoma patients.
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Background Malignant bone tumors of the distal tibia or fibula in children are rare. Quality of functional outcome following limb salvage surgery is still controversial. This is a retrospective review of the functional outcome of ankle arthrodesis using vascularized fibular flap. Methods A total of seven patients were reviewed. The diagnosis was osteosarcoma in five and Ewing's sarcoma in two patients. The primary tumor site was the distal tibia in six patients and the distal fibula in one patient. The average age at presentation was 10.6 years (range, 6.7–14 years). The average follow-up period was 24.5 months (range, 13–69 years). A pedicled fibular graft was harvested from the ipsilateral leg in two patients and a free vascularized osteocutaneous fibular flap from the contralateral leg in five patients. External fixation was used in five and internal fixation in two patients. Patients were allowed full weight bearing following radiographic evidence of complete bone union. Results The mean time to complete bone union and full weight bearing was 7.1 months (range, 4–13 months). One patient developed nonunion at graft-host junction and one patient had stress fracture of the fibular graft. The mean limb length inequality was 0.57 cm (range, 0–3 cm). The average Musculoskeletal Tumor Society (MSTS) score was 84.5% (range, 73–100%). Conclusion Skeletally immature patients treated by ankle arthrodesis using vascularized fibular flap can return to full weight bearing within the first year following surgery. A contralateral fibular flap has the advantage of preserving the contour of the ankle and reserving the ipsilateral fibula for initial stability at the fusion site. This study is of level IV evidence.
Article
Aims: We retrospectively report our experience of managing 30 patients with a primary malignant tumour of the distal tibia; 25 were treated by limb salvage surgery and five by amputation. We compared the clinical outcomes of following the use of different methods of reconstruction. Patients and methods: There were 19 male and 11 female patients. The mean age of the patients was 19 years (6 to 59) and the mean follow-up was 5.1 years (1.25 to 12.58). Massive allograft was used in 11 patients, and autograft was used in 14 patients. The time to union, the survival time of the reconstruction, complication rate, and functional outcomes following the different surgical techniques were compared. The overall patient survival was also recorded. Results: Out of 14 patients treated with an autograft, 12 (86%) achieved union at both the proximal and distal junctions. The time to union at both junctions of the autograft was significantly shorter than in those treated with an allograft (11.1 vs 17.2 months, p = 0.02; 9.5 vs 16.2 months, p = 0.04). The complication rate of allograft reconstruction was 55%. The five patients treated with an amputation did not have a complication. Out of the 25 patients who were treated with limb salvage, three (12%) developed local recurrence and underwent amputation. The mean functional Musculoskeletal Tumor Society (MSTS) score after autograft reconstruction was higher than after allograft reconstruction (81% vs 67%; p = 0.06), and similar to that after amputation (81% vs 82%; p = 0.82). The two- and five-year overall rates of survival were 83% and 70%, respectively. Conclusions: This consecutive case series supports the safety of limb salvage and the effectiveness of biological reconstruction after the resection of a primary tumour of the distal tibia. Autograft might be a preferable option. In some circumstances, below-knee amputation remains a valid option.
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Objective: Largest, single-centre study of clinical and functional outcomes of patients who underwent endoprosthetic replacement (EPR) for aggressive distal tibial bone tumours. Method: Retrospective observational study of eight patients was undertaken. Results: Median follow-up was 77 months (range 13-276). Cumulative five and ten year survival was 63% and 42% respectively. Three patients developed either disease recurrence or metastases post-surgery. One patient developed deep infection requiring washout and suppressive antibiotics. No patients required revision surgery. The median MSTS score at last follow up was 66%. Conclusions: EPR of the distal tibia is a viable option and provides good function outcomes.
Article
Background To investigate the effectiveness of tibiotalocalcaneal arthrodesis with a retrograde nail and allograft in limb salvage surgery for patients with distal tibia osteosarcoma. Methods 5 patients diagnosed as distal tibia osteosarcoma underwent ankle arthrodesis with a retrograde nail in our hospital. During the follow-up, radiographic views of the ankle joint were taken in two planes to assess bone healing and axis alignment. Other measurements of outcomes included procedure-related complications, local recurrence, and metastasis. Functional outcomes were evaluated with the Musculoskeletal Tumor Society (MSTS) scoring system. Results Postoperative complications occurred in 4 patients, including 4 cases of mild subcutaneous fluid and 1 case of screw breakage. All patients showed stable ankle and could stand or walk with the assistance of crutch before the complete union between allograft and host bone. One patient died due to multiple bone and pulmonary metastasis at 1 year after surgery. As for the other 4 patients, they were followed-up regularly for a mean period of 42 months. No local recurrence or distant metastasis occurred in any of these four patients. All the 4 patients expressed satisfaction with the outcome. According to MSTS scale, the mean postoperative functional score was 74.3% ± 4.4% (range, 70%–81%). Conclusions Intramedullary retrograde nail for distal tibia osteosarcoma could produce a satisfactory outcome in terms of functional results and complications. Excellent stabilization of the ankle joint can be achieved through this technique, as it allows patients to perform much earlier postoperative weight-bearing exercise.
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Interdisciplinary collaboration between orthopedic and plastic surgeons is indicated in reconstructive surgery of the extremities for both traumatic orthopedic fractures with extensive soft tissue damage and musculoskeletal tumor resection. We want to emphasize the need for close cooperation starting in the preoperative planning for reconstruction after tumor resection in order to discuss and establish a unified approach. This is particularly important to establish a joint approach with special consideration of possibly necessary adjuvant therapies. One collaborative approach is for the orthopedic surgeon to resect the tumor and the plastic surgeon to carry out the defect reconstruction for exclusive soft tissue coverage including flap surgery as well as for functional reconstruction depending on the location and extent of tumor resection. Thus, careful preoperative and postoperative communication on the precise location, extent of tumor resection and the therapy timing between the orthopedic surgeon and the plastic surgeon will allow the most effective subsequent repair of the resection site.
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Below knee amputation remains the treatment of choice for most patients with aggressive tumours of the distal tibia. We report the clinical and functional outcome of limb preserving surgery and endoprosthetic reconstruction of the distal tibia and ankle joint in five patients who declined amputation. The mean age was 32 years. Two had osteosarcoma, one Ewing's sarcoma, leiomyosarcoma and Giant cell tumour. Three patients developed significant complications including local recurrence, wound dehiscence and infection, and fibula impingement. Despite these complications the patients declined amputation even in the presence of significant discomfort. Early function was excellent in all patients but deteriorated with time. The patients still maintained an Enneking Score of more than 50%. Some patients are unwilling to undergo amputation for aggressive tumours of the distal tibia. For these, excision and reconstruction with endoprosthesis allow early functional recovery but there is significant medium term morbidity and functional deterioration.
Article
We conducted a randomized controlled trial to determine whether intensive multi-agent adjuvant chemotherapy improves the chances of relapse-free survival in patients with nonmetastatic high-grade osteosarcoma of the extremity, as compared with concurrent controls. After undergoing definitive surgery, 36 patients were randomly assigned to adjuvant chemotherapy or to observation without adjuvant treatment. At two years the actuarial relapse-free survival was 17 percent in the control group, similar to that found in studies before 1970, and 66 percent in the adjuvant-chemotherapy group (P less than 0.001). Similar results were observed among 77 additional patients who declined to undergo randomization but who elected observation or chemotherapy. We conclude that the natural history of osteosarcoma of the extremity has remained stable over the past two decades, that adjuvant chemotherapy increases the chances of relapse-free survival of patients with high-grade osteosarcoma, and that it should be given to all such patients.
Article
To determine the role of chemotherapy in the multidisciplinary treatment of patients with osteosarcoma, a randomized prospective trial of postoperative adjuvant chemotherapy was begun in 1981. Fifty-nine patients with nonmetastatic classic intramedullary osteosarcoma were randomized; 32 received postoperative adjuvant chemotherapy consisting of high-dose methotrexate, Adriamycin (Adria Laboratories, Columbus, OH), and BCD (bleomycin, cytoxan, actinomycin D), and 27 patients received no adjuvant chemotherapy. At a median follow-up of 2 years, there was a statistically significant improvement in both disease-free and overall survival in those who received adjuvant chemotherapy. In addition, there was no difference in the less than 20% disease-free or overall survival of patients treated in the 1970s who did not receive chemotherapy, as compared with the concurrent nontreatment controls. Therefore, with identical staging procedures, uniform surgical management, and standard pathologic evaluation, postoperative adjuvant chemotherapy definitely improves disease-free and overall survival in patients with osteosarcoma.
Article
We report a retrospective study of 62 total ankle arthroplasties performed between 1972 and 1981. Forty-one of these have been reviewed clinically after an average follow-up of five and a half years; only 13 can be described as satisfactory. The complications encountered in all 62 arthroplasties are detailed, the most significant being superficial wound healing problems, talar collapse, and loosening of the components; 13 prosthetic joints have already been removed and arthrodesis attempted. The management of the complications is discussed. In view of the high complication rate and the generally poor long-term clinical results, we recommend arthrodesis as the treatment of choice for the painful stiff arthritic ankle, regardless of the underlying pathological process.
Article
A surgical staging system for musculoskeletal sarcomas stratifies bone and soft-tissue lesions of any histogenesis by the grade of biologic aggressiveness, by the anatomic setting, and by the presence of metastasis. The three stages: I--low grade; II--high grade; and III--presence of metastases, are subdivided by (a) whether the lesion is anatomically confined within well-delineated surgical compartments, or (b) beyond such compartments in ill-defined fascial planes and spaces. Operative margins are defined as intralesional, marginal, wide, and radical, and relate the surgical margin to the lesions, its reactive zone, and anatomic compartment. The system defines prognostically significant progressive stages of risk which also have surgical implications. When the system is linked to clearly defined surgical procedures, it permits appropriate evaluation and comparison of the new treatment protocols designed to replace standard surgical treatment.
Article
The authors report 12 cases of bone tumors localized in the distal tibia treated by resection and reconstruction with ankle arthrodesis, using bone grafts and fixation with Kuntscher or Grosse-Kempf nail or plate. In seven cases autografts were used, and in five cases autografts combined with allografts were used. In three of these five patients, a vascularized fibula combined with a "gutter-like" allograft was used to reconstruct the bone defect. In all cases, the functional and oncologic results were good and all patients were disease free at an average follow-up of 68 months.
Article
Reconstruction after massive loss of bone about the ankle is difficult because of the limited amount of surrounding soft tissue and because of technical factors pertaining to adequate internal or external fixation. Conventional techniques are often unsuccessful because of the frequency of associated deep infection and of previous operative procedures. In this report, we describe eleven patients with a large defect of the distal aspect of the tibia who were managed at our institution with arthrodesis of the ankle with free vascularized bone graft. The defect was related to a tumor resection; an acute open fracture with bone and soft-tissue loss caused by a shotgun injury; or osteomyelitis, either alone or in combination with septic arthritis, with chronic non-union following a fracture of the ankle. A free fibular graft was used in osseous defects that were larger than four centimeters, and a free iliac-crest graft was used in smaller defects. Osteocutaneous or osteomuscular flaps were constructed to cover accompanying soft-tissue defects when necessary. A successful fusion was obtained in nine of the eleven patients. The results in the remaining two were regarded as clinical failures, and a below-the-knee amputation was performed. One amputation was done because of recurrent infection and the other, because of failure of the fracture to unite after four years.
Article
Two hundred and four primary Mayo total ankle arthroplasties were performed in 179 patients at the Mayo Clinic from 1974 through 1988. We evaluated the clinical result after 160 arthroplasties in 143 patients who had been followed for two years or more (mean, nine years; range, two to seventeen years). The result was good for thirty-one ankles (19 per cent), fair for fifty-five (34 per cent), and poor for seventeen (11 per cent); fifty-seven arthroplasties (36 per cent) were considered to be a failure (defined as removal of the implant). Adequate preoperative and follow-up radiographs were available for 101 ankles (eighty-nine patients). There was radiographic evidence of loosening of eight tibial components (8 per cent) and fifty-eight talar components (57 per cent), but we found no association between the clinical and radiographic results. Complications occurred after nineteen (12 per cent) of the 160 arthroplasties, and ninety-four additional reoperations were necessary after sixty-six (41 per cent). On the basis of these findings, we do not recommend ankle arthroplasty with a constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle.
Article
We have carried out prosthetic reconstruction in six patients with malignant or aggressively benign bone tumours of the distal tibia or fibula. The diagnoses were osteosarcoma in four patients, parosteal osteosarcoma in one and recurrent giant-cell tumour in one. Five tumours were in the distal tibia and one in the distal fibula. The mean duration of follow-up was 5.3 years (2.0 to 7.1). Reconstruction was achieved using custom-made, hinged prostheses which replaced the distal tibia and the ankle. The mean range of ankle movement after operation was 31 degrees and the joints were stable. The average functional score according to the system of the International Society of Limb Salvage was 24.2 and five of the patients had a good outcome. Complications occurred in two with wound infection and talar collapse. All patients were free from neoplastic disease at the latest follow-up. Prosthetic reconstruction may be used for the treatment of malignant tumours of the distal tibia and fibula in selected patients.