Extensor Mechanism-Sparing Technique for Management of Proximal Tibia Sarcoma Resection: A Case Series Study

Case Series

Austin J Orthopade & Rheumatol. 2021; 8(3): 1105.

Extensor Mechanism-Sparing Technique for Management of Proximal Tibia Sarcoma Resection: A Case Series Study

Fazioli F1, Ruosi C2*, Colella G3, Gallo M1 and de Nigris F4*

1Division of Skeletal Muscle Oncology Surgery, National Cancer Institute G. Pascale Foundation, IRCCS, Naples, Italy

2Orthopaedic Unit, Department of Public Health, School of Medicine “Federico II” University, Naples, Italy

3Ospedale Santobono UOC Ortopedia e Traumatologia, Naples, Italy

4Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy

*Corresponding author: Carlo Ruosi, Orthopaedic Unit, Department of Public Health, School of Medicine “Federico II” University, 80131, Naples, Italy

Filomena de Nigris, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80138, Naples, Italy

Received: November 23, 2021; Accepted: December 15, 2021; Published: December 15, 2021;

Abstract

The proximal tibia is one of the most challenging anatomic sites for resection of large bone tumors, due to the vicinity of the extensor mechanism. Here, we report outcomes of a novel radical resection technique which preserves the extensor apparatus. 8 patients were operated between 2001 and 2011 for large sarcomas with high-grade tibial localization. Six were giant cell tumor of bone histology (GCTB; defined as severe bone destruction and soft tissue extension) and two chrondrosarcoma at surgical grade G1, but with double localization in tibia and femur. Primary bone tumors and recurrences were treated with novel multiplanar resection technique avoiding removal of the tibial tuberosity and the patella tendon insertion, preserving extensor mechanism. In all cases, curettage and borage were not indicated due to extensive lesion size. Radical resection of the lower extremity (2 femurs and 8 tibias) yielded wide margins (R0) and patients were evaluated at 10 years of follow up. The average post operative Musculoskeletal Tumor Society (MSTS) score was 26.87 points (range: 23-29). All patients reached full passive and active extension and the maximum active flexion was 108.75° (range: 90°-120°). At the last follow-up (mean: 121.8 months), all patients and implants survived; no local infection, recurrence, metastasis, or relevant complications occurred. This surgical technique therefore appears to provide a safe treatment option when wide surgical margins are possible, and preserving the integrity of the extensor mechanism may improve the clinical outcome.

Keywords: Limb Salvage; Bone and Bones; Tibia; Extensor Mechanism

Introduction

Despite numerous surgical options, the reconstruction of the extensor mechanism after en bloc surgery of proximal tibia bone tumor, represents a challenge that significantly influences the clinical and functional outcome [1-5]. Reconstruction of the knee extensor mechanism is among the leading causes of poor function after surgery [1,6,7]. Generally, patients showed extensor lag and insufficient active extension of the knee [2,8,9]. Currently, there are a number of techniques for extensor-mechanism reconstruction. One is the direct attachment of the extensor mechanism to the proximal tibia mega-prosthesis. However, the failure of the patellar tendon–metal junction, and infections are common complications [10-12]. Another method is the reattachment of the extensor mechanism to the tibia allograft. Although the use of the allograft shows better results in the restoration of the extensor mechanism, the osteoarticular allograft reconstruction is not technically easy. The patients have a longer period of immobilization, associated with higher complication rates such as infections, fractures, subchondral collapse, articular cartilage degeneration, and instability [6]. Allograft prosthesis composites (APC) were introduced in order to combine the advantages of a prosthesis, such as better range of motion, load-sharing properties, articular stability, with biologic insertion of soft tissues to reduce subchondral fractures [13-16]. However, many studies reported that these reconstruction techniques of proximal tibia showed an higher index of complications, compared to other anatomic sites, e.g. the distal femur [17-22].

In contrast, the proposal surgical procedure for proximal tibia resection preserves the continuity of the extensor mechanism in order to improve the functional outcome. This procedure is feasible for tumours not localized on the anterior portion of the tibia and when curettage is not possible. Furthermore, precise pre-operative planning is essential to assess whether it is possible to obtain wide resection margins, thereby leaving intact an adequate anterior tibia splint containing the insertion of the patellar tendon, in continuity with the distal portion of the tibia. We here present data from patients undergoing this procedure, and analyze their functional and clinical outcomes.

Methods and Materials

Patients

8 patients with sarcomas localized in the proximal tibia (6 giant cell of bone tumors and 2 chondrosarcoma histologies) who were surgically treated at the orthopedics unit of the Istituto Tumori G. Pascale (Naples, Italy) between January 2001 and January 2011, using a new surgical extensor mechanism-sparing technique. The inclusion criteria were an indication for radical surgery and the possibility to achieve wide surgical margins (in our population, at least 81.6 mm for GCTB recurrence and 220mm for chondrosarcoma longitudinal length of resection), in order to preserve an adequate anterior tibial cortex splint for our surgical protocol. Patients with less than two years of follow-up were excluded. The follow-up time was calculated from the date of surgical resection to the most recent follow-up visit. The mean follow-up duration in our population was 120 months.

The research was conducted in accordance with the Declaration of Helsinki and Italian and institutional standards. All patients provided written informed consent prior to inclusion in the study.

Surgery plan and protocol

For all patients, we obtained multiplanar and multisequence magnetic resonance images (MRI) to plan resection. No patient underwent neo-adjuvant chemotherapy or radiotherapy. We used an anterior approach to the knee with an anterior incision extended distally on the leg based on the bone resection, and a para-patellar medial arthrotomy. Two longitudinal tibial osteotomies were then performed on two sagittal planes, one medial and one lateral to the insertion of the patellar ligament (Figure 1 and 2). Distally, we performed a circumferential osteotomy parallel to the superior osteotomy, leaving the anterior portion of the tibia intact to allow continuity of the splint bone with the portion of the tibia distal to resection.