1
|
Motta DPDA, Arruda BG, Pinheiro RDECES, Ribeiro GA, Delocco BC, Fiorelli BDEO, Witte EAL, Meohas W. RESECTION OF ANKLE TUMOR LESION AND RECONSTRUCTION WITH THE USE OF ALLOGRAFT. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e266018. [PMID: 37876870 PMCID: PMC10592342 DOI: 10.1590/1413-785220233105e266018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/26/2022] [Indexed: 10/26/2023]
Abstract
Reconstruction of the distal third of the tibia due to resection of a malignant tumor has some hindering factors, such as a thin subcutaneous layer, neurovascular bundles that cross compartments, prolonged operative duration, specific orthopedic material, and a trained multidisciplinary team. Allografting with material from tissue banks is part of this orthopaedic arsenal. OBJECTIVE To describe the protocol used at Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad. METHODS Series of six cases subjected to resection with oncologic margins, allograft reconstruction, and use of a retrograde ankle nail as limb-salvage surgery. Three of the six patients were women, the lesions were on average 9.3 cm long, and the average operative duration was 3.25 hours. RESULTS The main short-term complication (≤ 30 days) was peroneal nerve palsy, while the main long-term complication (> 30 days) was surgical site infection (two cases). Consolidation of the two foci occurred in three patients, and two patients developed asymptomatic pseudoarthrosis of the proximal focus with consolidation of the distal focus. CONCLUSION Despite the complications, the proposed surgery gives patients the chance to preserve their limb in the face of immediate radical surgery. Level of Evidence IV, Case Series.
Collapse
Affiliation(s)
- Diego Perez DA Motta
- Fellow in Oncological Orthopedics, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil
| | - Beatriz Gomes Arruda
- Orthopedic Resident, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil
| | - Rafael DE Castro E Silva Pinheiro
- Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Centro de Atenção Especializada em Ortopedia Oncológica, Rio de Janeiro, RJ, Brazil
| | - Gabriel Araújo Ribeiro
- Orthopedic Resident, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil
| | - Bruna Canteri Delocco
- Fellow in Oncological Orthopedics, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil
| | - Bruno DE Oliveira Fiorelli
- Fellow in Oncological Orthopedics, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil
| | - Eduardo Alessandro Lima Witte
- Fellow in Oncological Orthopedics, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil
| | - Walter Meohas
- Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Centro de Atenção Especializada em Ortopedia Oncológica, Rio de Janeiro, RJ, Brazil
| |
Collapse
|
2
|
Cao ZM, Sui XL, Xiao Y, Qing LM, Wu PF, Tang JY. Efficacy comparison of vascularized iliac crest bone flap and Ilizarov bone transport in the treatment of traumatic bone defects of the tibia combined with large soft tissue defects. J Orthop Surg Res 2023; 18:349. [PMID: 37170110 PMCID: PMC10176677 DOI: 10.1186/s13018-023-03783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 04/05/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Traumatic tibial defect complicated with soft tissue defect is a difficult problem in clinic. Vascularized iliac crest bone flap (VIBF) and Ilizarov bone transport are effective methods to treat tibial defects with limited defect length, which most need to be explored accordingly. METHODS In this study, a total of 68 patients with traumatic tibial defect (ranging from 4 to 10 cm) and large soft tissue defect were collected retrospectively. The soft tissue defects were repaired by latissimus dorsal musculocutaneous flap (LD), anterolateral thigh flap (ALTF) or both. Thirty-three cases were treated with vascularized iliac crest bone flap transplantation and 35 cases were treated with Ilizarov bone transport. Intraoperative and postoperative follow-up data (including operation time, blood loss, bone union time, external fixation time, external fixation index, complication rate, reoperation rate, and functional evaluation) were recorded, and comparative analysis was performed. RESULTS The median follow-up time was 32 months. Compared with Ilizarov group, the VIBF group exhibited statistically faster bone union time (6.3 ± 1.0 vs. 18.2 ± 3.0 months). Moreover, the VIBF group showed shorter EFT (7.3 ± 1.0 vs. 19.2 ± 3.0 months) and a better EFI (34.8 ± 9.2 vs. 84.2 ± 23.7 days/cm). The excellent and good rate of lower limb appearance evaluation in VIBP group was significantly better than that in Ilizarov group. The complication rate and reoperation rate were significantly higher in Ilizarov group. CONCLUSION In summary, compared with Ilizarov bone transport, VIBP has the advantages of faster healing, shorter external fixation time, lower complication and reoperation rate, and better appearance within the limited defect length. Ilizarov bone transport is still preferred when the defect length exceeds the maximum repair length of the iliac flap. The daily handling required by bone transport process is painful. LEVEL OF EVIDENCE III, Case-control study.
Collapse
Affiliation(s)
- Zhe-Ming Cao
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Xin-Lei Sui
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yu Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Li-Ming Qing
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Pan-Feng Wu
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| | - Ju-Yu Tang
- Department of Orthopedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| |
Collapse
|
3
|
Buldu MT, Sacchetti F, Yasen AT, Furtado S, Parisi V, Gerrand C. Return to sports following lower limb musculoskeletal tumor surgery-A systematic review. Scand J Med Sci Sports 2023. [PMID: 37157882 DOI: 10.1111/sms.14382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/23/2022] [Accepted: 04/15/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Survivors of primary malignant musculoskeletal tumors often face long-term disability. Clinicians at present are unable to provide evidence-based advice about returning to sports, which is important for active patients. PURPOSES Identify patients returning to sports. Describe the sporting activities in which patients participate. Identify the outcome measures used to assess return to sport. Identify barriers preventing return to sports. STUDY DESIGN Systematic review. METHODS A comprehensive search strategy was used to identify relevant studies combining the following concepts: (1) Bone/Soft tissue tumor, (2) Lower limb, (3) Surgical interventions, and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors (MTB, FS, and CG). RESULTS Twenty-two studies were selected, published between 1985 and 2020, including 1005 patients. Fifteen of the 22 studies had valid data on return to sports, with 705 participants, of which 412 (58.4%) returned to some form of sport such as swimming and cycling, at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing surgery and amputation; none of these were able to identify a difference in sports participation or ability. CONCLUSION There is insufficient published research to provide guidance for patients with respect to return to sports following musculoskeletal tumors. Future prospective studies are needed to collect better pre- and post-treatment data at multiple time intervals. Validated clinical and patient sports participation outcomes such as type of sports, level, frequency, and validated sports-specific outcome scores should be recorded. In particular, more comparison between limb sparing surgery and amputation would be welcome.
Collapse
Affiliation(s)
| | - Federico Sacchetti
- Ortopedia Oncologica e Ricostruttiva, CTO-Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Adam T Yasen
- Royal National Orthopaedic Hospital, Middlesex, UK
| | | | | | | |
Collapse
|
4
|
Rosli MA, Sulaiman WAW, Ismail WFW, Yahaya S, Saad AZM, Wan Z, Halim AS. Functional outcomes in total talus reconstruction with triangular double-barrel free fibula flap following oncological resection: A retrospective case series review. J Plast Reconstr Aesthet Surg 2021; 75:641-650. [PMID: 34756555 DOI: 10.1016/j.bjps.2021.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 09/04/2021] [Accepted: 09/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND With the advent of new techniques, foot salvage is feasible following talus oncological resection. As the reconstruction aims to achieve a pain-free, stable ankle for ambulation, biological limb reconstruction is the best option. This case series will evaluate the primary indications, complications, and functional outcomes of the reconstructed talus and highlighting the technical aspects of the surgery with a novel technique of triangular double-barrel free fibula flap. METHODS We performed a retrospective case note review of patients undergoing foot salvage surgeries and primary talus reconstruction with double-barrel free fibula flaps between 2009 and 2019. Patient demographics, aetiologies, operative details, complications, and outcomes were analysed. All patients underwent the same talar reconstruction technique whereby a wide-based triangular framework was created from two bony struts of the osteotomized fibula. The Musculoskeletal Tumour Society (MSTS) scoring system was used to analyse the short- to mid-term functional outcomes. RESULTS Four consecutive patients with aggressive benign and malignant tumours were identified. They consist of three males and one female, with a median age of 32 (range 27-39). Patients were followed up for a median duration of 60 months (range 24-132). Two flaps were complicated with venous thromboses; however, all were salvageable following re-explorations. All patients achieved solid bony fusion with good functional and aesthetic outcomes. The median MSTS score was 74.5% (range 66-76). No donor site morbidity and local recurrence were reported. CONCLUSION The triangular double-barrel free fibular flap is a good option for limb salvage following total talus resection, with good short- to mid-term functional and aesthetic outcomes.
Collapse
Affiliation(s)
- Mohamad Aizat Rosli
- Hospital Universiti Sains Malaysia, Medical Campus, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Reconstructive Sciences Unit, School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Wan Azman Wan Sulaiman
- Hospital Universiti Sains Malaysia, Medical Campus, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Reconstructive Sciences Unit, School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Wan Faisham Wan Ismail
- Hospital Universiti Sains Malaysia, Medical Campus, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Orthopaedic Oncology and Reconstructive Unit (OORU), School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia.
| | - Sahran Yahaya
- Hospital Universiti Sains Malaysia, Medical Campus, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Orthopaedic Oncology and Reconstructive Unit (OORU), School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Arman Zaharil Mat Saad
- Reconstructive Sciences Unit, School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Plastic & Reconstructive Unit, MSUMC, Management and Science University, University Drive, Off Persiaran Olahraga, Shah Alam, Selangor 40100, Malaysia
| | - Zulmi Wan
- Orthopaedic Oncology and Reconstructive Unit (OORU), School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Orthopaedic Oncology and Reconstructive Unit (OORU), Prince Court Medical Centre, Jalan Kia Peng, Kuala Lumpur, Kuala Lumpur 50450, Malaysia
| | - Ahmad Sukari Halim
- Hospital Universiti Sains Malaysia, Medical Campus, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia; Reconstructive Sciences Unit, School of Medical Sciences, Medical Campus. Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| |
Collapse
|
5
|
Wirth T, Manfrini M, Mascard E. Lower limb reconstruction for malignant bone tumours in children. J Child Orthop 2021; 15:346-357. [PMID: 34476024 PMCID: PMC8381393 DOI: 10.1302/1863-2548.15.210126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 02/03/2023] Open
Abstract
Malignant bone tumours of the lower limb represent the majority of cases in both osteosarcoma and Ewing sarcoma in the growth period. Surgical treatment represents a key element of treatment. Different localizations and age groups require a differentiated surgical approach. Life and limb salvage are first on the list of treatment goals, followed by functional and cosmetic considerations. This review article delivers and discusses current surgical treatment strategies and outcomes for lower limb malignant bone tumours in children.
Collapse
Affiliation(s)
- Thomas Wirth
- Department of Orthopaedics, Klinikum Stuttgart, Olgahospital, Stuttgart, Germany,Correspondence should be sent to T. Wirth, MD, PhD, Department of Orthopaedics, Klinikum Stuttgart, Olgahospital, Kriegsbergstraße 62, D-70174 Stuttgart, Germany. E-Mail:
| | - Marco Manfrini
- Department of Musculoskeletal Oncology Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eric Mascard
- Department of Paediatric Orthopaedic Surgery, Necker University Hospital, Paris, France
| |
Collapse
|
6
|
Zhao Z, Yan T, Guo W, Yang R, Tang X. Is double-strut fibula ankle arthrodesis a reliable reconstruction for bone defect after distal tibia tumor resection?-a finite element study based on promising clinical outcomes. J Orthop Surg Res 2021; 16:230. [PMID: 33781282 PMCID: PMC8006370 DOI: 10.1186/s13018-021-02362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/18/2021] [Indexed: 11/26/2022] Open
Abstract
Background There are different surgical methods for primary malignant tumor located at distal tibia. Previous studies have reported that double-strut fibula ankle arthrodesis is an alternative option. The purpose of this study was to investigate the biomechanical effect of double-strut fibula ankle arthrodesis by finite element analysis (FEA). Methods Computer-aided design software was used to establish three-dimension models. Three different models were constructed: normal tibia-fibula-talus complex (model A), double-strut fibula ankle arthrodesis (model B), and reconstruction by ipsilateral fibula (model C). We used FEA to evaluate and compare the biomechanical characteristics of these constructs. Simulated load of 600 N was applied to the tibial plateau to simulate balanced single-foot standing. Output results representing the model von Mises stress and displacement of the components were analyzed. Results Construct stiffness was increased when the internal plate fixation was used. For axial load, model B (1460.5 N/mm) was stiffer than the construct of model A (524.8 N/mm), and model C (636.6 N/mm), indicating model B was more stable. Maximum stress on the fibular graft occurred on the proximal end. The von Mises stress and stress distribution of fibular graft in model B (71.4 MPa) and model C (67.8 MPa) were similar. In model B, the ipsilateral fibula in model B has a higher value of stress (16.1 MPa) than that in model A (0.5 MPa), indicating the ipsilateral fibula shared load after fusion with talus. Conclusions Our computational findings suggest that double-strut fibula ankle arthrodesis is an acceptable construct for distal tibia defect and the ipsilateral fibula shares load after fusion with talus. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02362-0.
Collapse
Affiliation(s)
- Zhiqing Zhao
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| |
Collapse
|
7
|
Reconstructive Challenges of Distal Tibia Bone Tumors: Extracorporeally Irradiated Autograft Combined with a Nonvascularized Autograft Fibula for Superior Reconstruction and Functional Outcomes When Compared to Ipsilateral Pedicled Fibula Transfer Alone. Sarcoma 2021; 2021:6624550. [PMID: 33814963 PMCID: PMC8012118 DOI: 10.1155/2021/6624550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
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 (p=0.068). 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.
Collapse
|