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Fan QH, Long S, Wu XK, Fang Q. Management of a rare giant cell tumor of the distal fibula: A case report. World J Clin Cases 2023; 11:394-400. [PMID: 36686354 PMCID: PMC9850983 DOI: 10.12998/wjcc.v11.i2.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/07/2022] [Accepted: 10/24/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Aggressive giant cell tumor of the distal fibula is so rare that no consensus on a surgical strategy has been reached. Thus, an appropriate treatment strategy is still important to discuss.
CASE SUMMARY A 61-year-old man who had been experiencing progressive swelling of the left lateral malleolus accompanied by pain for half a year was presented at our hospital. He had never been treated prior to coming to our hospital. Preoperative imaging revealed a 10 cm × 6 cm mass located in the body of the distal fibula. Pathological biopsies confirmed it was a giant cell tumor. Preoperative examination revealed he had dilated cardiomyopathy with class 3 cardiac function. The cardiologist and anesthesiologist determined that he could tolerate the operation, but the operation should be as short and minimally invasive as possible. With the patient’s consent, we performed a tibiotalar fusion and followed up with him for 2 years, finding no recurrence and a satisfactory recovery.
CONCLUSION Tibial talus fusion is an effective method for the treatment of distal fibula tumors.
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Affiliation(s)
- Qing-Hong Fan
- Department of Orthopaedics, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Shan Long
- Department of Neonatology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Xing-Kai Wu
- Department of Orthopaedics, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Qin Fang
- Department of Orthopaedics, The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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Go R, Lee L, Vijayakumar G, Tepper S, Gitelis S, Blank A. Epithelioid hemangioendothelioma of the distal lower extremity and the role of radiotherapy: A report of two cases. Rare Tumors 2023; 15:20363613231172611. [PMID: 37124838 PMCID: PMC10134116 DOI: 10.1177/20363613231172611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 05/02/2023] Open
Abstract
We report two cases of epithelioid hemangioendothelioma (EHE) in the distal lower extremity. Our first patient had unicentric EHE of the left os calcis initially treated with an intralesional procedure; however, later developed two recurrences which were managed with radiation therapy. Our second patient had multicentric EHE of the distal tibia and fibula managed with primary radiation therapy. Although EHE is typically treated with wide resection or an intralesional procedure, we present two cases of EHE in the distal lower extremity to discuss the therapeutic role of radiation therapy in the management of distal EHE.
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Affiliation(s)
| | | | - Gayathri Vijayakumar
- Gayathri Vijayakumar, BS, Department of Orthopedic Surgery, Section of Orthopedic Oncology, Rush University Medical Center, 1611 West Harrison St, Chicago, IL 60612-3801, USA.
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Savvidou OD, Gavriil P, Trikoupis I, Kaspiris A, Melissaridou DE, Papakonstantinou O, Korkolopoulou P, Papagelopoulos PJ. Three-dimensional Printed Endoprosthesis for Reconstruction of the Distal Tibia and Ankle Joint After Tumor Resection. Orthopedics 2022; 45:e348-e352. [PMID: 35858153 DOI: 10.3928/01477447-20220706-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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. 2022;45(6):e348-e352.].
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Liang H, Wang J, Yang Y, Niu T, Du Z, Zang J, Wei R, Yan T, Tang X, Guo W. Reconstruction With a 3D-Printed Megaprosthesis With Ankle Arthrodesis After Distal Tibial Tumor Resection. Foot Ankle Int 2022; 43:1450-1459. [PMID: 35932107 DOI: 10.1177/10711007221115188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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. 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.
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Affiliation(s)
- Haijie Liang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Jichuan Wang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Yi Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Tianli Niu
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Zhiye Du
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Jie Zang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Ran Wei
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Xicheng District, Beijing, China
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Wang S, Luo Y, Zhang Y, Wang Y, Zheng C, Tu C, Zhou Y. Case Report: Reconstruction of Medialis Malleolus (1/4 of the Ankle Joint) After Resection of Distal Tibia Tumor With an Uncemented Three-Dimensional-Printed Prosthesis. Front Surg 2022; 9:844334. [PMID: 35402484 PMCID: PMC8987288 DOI: 10.3389/fsurg.2022.844334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Few 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 Description A 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.
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Xu S, Liu Y, Zhu G, Liu K, Tang J, Wu J, Yan A, Jiang F, Mo S, Mei H. Evaluation of the efficacy of ipsilateral fibular transfer for reconstruction of large tibial defects in children: a retrospective study. J Orthop Surg Res 2022; 17:142. [PMID: 35248095 PMCID: PMC8898503 DOI: 10.1186/s13018-022-03021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Reconstruction of large tibial defects is often a major challenge in limb salvage. This study aimed to evaluate initial follow-up results of ipsilateral fibula transfer for the treatment of large tibial defects in children.
Methods A retrospective study was performed between September 2014 and April 2021. Ten children were identified as having large tibial defects. The children underwent ipsilateral fibula transfer. We then evaluated initial healing, tibial length discrepancy, ankle varus/valgus, fibular position, refracture, infection, and function. Results Five boys and five girls, with an average age of 7.2 years, were evaluated. The transferred fibula was united in the patients. The mean follow-up period after fibular transposition was 43 months. The patients achieved primary bone union; the mean time to union was 8.4 months (range, 4–18 months). Complications included refracture (30%), infection (40%), tibia malunion (30%), ankle varus (30%), sensory loss of toes (10%), and ankle valgus (10%). No other major complications were observed. All 10 patients were able to perform activities of daily living and return to their normal activities. Conclusion Ipsilateral fibula transfer is a salvage surgery for the treatment of large tibial defects in children with congenital pseudoarthrosis of the tibia, traumatic nonunion of the tibia, and/or tibial defect after chronic osteomyelitis. However, long-term results still need to be followed up.
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Kumar TKJ, Pai PK, Rajasubramanya P. A Rare Case of Ewing's-like Adamantinoma of Tibia Managed by Limb Salvage Surgery Using Long Segment Ilizarov Bone Transport: A Case Report and Review of Literature. J Orthop Case Rep 2021; 11:61-67. [PMID: 34557442 PMCID: PMC8422014 DOI: 10.13107/jocr.2021.v11.i05.2208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Adamantinoma is a rare low-grade malignant tumor in young adults. Recent advances in molecular techniques have shown different variants with discordance between genotype and phenotype. This poses a challenge in diagnosis and management. Ewing’s-like adamantinoma is one such variant. The appropriate treatment protocol for this dedifferentiated tumor remains to be established. Here, we present a rare case of Ewing’s-like Adamantinoma treated with limb salvage surgery using three step Ilizarov technique with good results. Case Report A 38-year-old lady presented at our OPD complaining of recent onset pain and gradual increase in size over a long standing swelling in the right lower tibia. Radiologically was diagnosed as Ewing’s but was not responsive to chemotherapy. A Tru-Cut biopsy showed histological picture of dedifferentiated adamantinoma. Immunohistochemistry showed CD99 positivity. FISH revealed (11;22) translocation confirming Ewing’s-like adamantinoma. She was managed with wide excision followed by staged Ilizarov distraction-osteogenesis and bone transport to correct the 13 cm discrepancy in bone length. There have been no signs of recurrence on post-resection follow-up of 2 years. Patient attained full range of knee and ankle movements. Conclusion The controversy as to what constitutes the difference between adamantinoma-like Ewing’s and Ewing’s-like adamantinoma persists despite technological advances. The appropriate treatment protocol remains to be established. Ilizarov three step techniques provide a feasible alternative to amputation while circumventing the difficulties of large bone reconstruction in the distal tibia.
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Affiliation(s)
- T K Jeejesh Kumar
- Department of Orthopedics, Government Medical College, Kozhikode, Kerala, India
| | - Puneeth K Pai
- Department of Orthopedics, Government Medical College, Kozhikode, Kerala, India
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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.
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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
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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.
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Barsales KA, Javier J, Catibog JJ, de Dios AV, Wang EH. Huge Intraosseous Tibial Haemangioma Managed with Embolisation, Excision and Fibular Ilizarov Reconstruction: A Case Report. Strategies Trauma Limb Reconstr 2021; 16:60-63. [PMID: 34326904 PMCID: PMC8311747 DOI: 10.5005/jp-journals-10080-1518] [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] [Indexed: 11/23/2022] Open
Abstract
Aim Our aim is to report the successful treatment of an intraosseous haemangioma of tibia with an atypical presentation through a multidisciplinary approach of preoperative embolisation, a subtotal resection of the tibia and subsequent reconstruction with the Ilizarov medial fibular translation technique. Background En bloc excision is the treatment of choice for large tumours of the tibia. However, there is no single recommended method for the reconstruction of the resulting bony defect. Case A 22-year-old female presented with a massive intraosseous haemangioma of the entire tibia. Sequential, multimodal treatment consisted of (1) preembolisation, (2) en bloc resection and (3) reconstruction of the extensive skeletal defect via the Ilizarov method of fibular medialisation. Radiologic union occurred at 6 months and graft hypertrophy at 22 months. At 45 months, the patient was fully weight-bearing without need for an assistive device. Conclusion Resection and reconstruction of a large intraosseous haemangioma of the tibia can be treated successfully using a well-planned sequential management of embolisation, resection and Ilizarov fibular grafting. Significance This report highlights the successful management of an unusually extensive and difficult tumour through appropriate and meticulous perioperative multidisciplinary planning, execution and follow-up. How to cite this article Barsales KAD, Javier J, Catibog JJ, et al. Huge Intraosseous Tibial Haemangioma Managed with Embolisation, Excision and Fibular Ilizarov Reconstruction: A Case Report. Strategies Trauma Limb Reconstr 2021;16(1):60–63.
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Affiliation(s)
- Ken Ad Barsales
- Department of Orthopedics, University of the Philippines - Philippine General Hospital, Manila, Philippines
| | - Juanito Javier
- Department of Orthopedics, Ilizarov Section, University of the Philippines - Philippine General Hospital, Manila, Philippines
| | - Jolly J Catibog
- Department of Radiology, Section of Interventional Radiology, University of the Philippines - Philippine General Hospital, Manila, Philippines
| | - Ariel Vergel de Dios
- Department of Pathology, Section of Musculoskeletal Tumor Pathology, University of the Philippines - Philippine General Hospital, Manila, Philippines
| | - Edward Hm Wang
- Department of Orthopedics, Tumor Section, University of the Philippines - Philippine General Hospital, Manila, Philippines
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Wang J, Du Z, Yang R, Tang X, Guo W. Lateral malleolus en bloc resection for the distal fibula osteosarcoma based on a new classification and proposed reconstruction choice: Analysis of 6 cases prognosis and literature review. Foot Ankle Surg 2020; 26:855-863. [PMID: 31874789 DOI: 10.1016/j.fas.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 09/21/2019] [Accepted: 11/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Amputation has been regarded as the standard surgical treatment for distal fibula osteosarcoma. With the advances in surgery and adjuvant chemotherapy, it have made limb salvage possible. However, the choice of a specific reconstruction procedure is frequently based on the surgeon's preference and it lacks of guidelines and high quality studies with the objective result on the subject. MATERIALS AND METHODS Six patients with the distal fibular osteosarcoma which were received biological reconstruction were retrospectively reviewed at our bone tumor center from November 2003 to November 2015. There were 6 male with a mean age of 24.2 years (range, 12-47 years). The minimum follow-up duration was 53.3 months (median, 96.3 months; average, 108.4 months; range, 53.3-204.1 months). No patient was lost at the last follow-up. All data were obtained from the clinical and radiograph records. Furthermore, the literature review was based on the Google Scholar, Medline, EMBASE and Pubmed databases. The search was performed using the terms "distal fibula", "lower limb tumour", "sarcoma", "fibular metastasis" and "limb-salvage surgery" for the literature review from 1979 to 2017. RESULTS Of the six patients with the final follow-up in the present study, four cases (83.3%, 4/6) achieved excellent prognosis without oncologic complications. A second surgical procedure was performed in two patients, one to treat local recurrence and one to receive metastasectomy due to the pulmonary metastasis. Case 6 received the below knee amputation due to recurrence. All the cases available for functional evaluation at the final follow-up had a mean functional MSTS score of 29.6 (range, 28-30) except case 6 receiving the amputation below the knee. Meanwhile, the VAS evaluation had a mean functional score of 0.2 points (range, 0-1 points). The results of our cohort and literature review illustrated that the patient with the malignant tumor of lateral malleolus could obtain excellent oncological prognosis and ankle function. CONCLUSIONS We have provided treatment recommendations depending on the tumor volume and associated extent and proposed the primary ankle arthrodesis was performed after en bloc resection of Type II and III lateral malleolus osteosarcoma, based on the proposed classification. Furthermore, the patient with the malignant tumor of lateral malleolus could obtain excellent oncological prognosis.
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Affiliation(s)
- Jun Wang
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xizhimen South Street, 100044 Beijing, China.
| | - Zhiye Du
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xizhimen South Street, 100044 Beijing, China.
| | - Rongli Yang
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xizhimen South Street, 100044 Beijing, China.
| | - Xiaodong Tang
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xizhimen South Street, 100044 Beijing, China.
| | - Wei Guo
- Peking University People's Hospital, Musculoskeletal Tumor Center, No. 11 Xizhimen South Street, 100044 Beijing, China.
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Limb Salvage and Reconstruction Options in Osteosarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1257:13-29. [PMID: 32483727 DOI: 10.1007/978-3-030-43032-0_2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in chemotherapy, sophisticated imaging, and surgical techniques over the last few decades have allowed limb-salvage surgery (LSS) to become the preferred surgical treatment for bone sarcomas of the extremities. The goal of LLS is to maximize limb functionality to allow for the maintenance of quality of life without compromising overall survival and tumor local recurrence rates. Today, limb-salvage procedures are performed on 80-95% of patients with extremity osteosarcoma, and the 5-year survival rate in extremity osteosarcoma patients is now 60-75%.This chapter will focus on LSS for extremity osteosarcoma. Common types of surgical reconstruction techniques including endoprostheses, intercalary or osteoarticular allografts, vascularized fibular autografts, and allograft prosthetic composites (APC), and their complications such as infection, local recurrence, graft fracture, implant failure, and nonunion will be discussed in detail. Anatomic locations of lesions discussed include the proximal femur, distal femur, proximal tibia, distal tibia, proximal humerus, distal humerus, and forearm bones.
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Zhao Z, Yan T, Tang X, Guo W, Yang R, Tang S. Novel "double-strut" fibula ankle arthrodesis for large tumor-related bone defect of distal tibia. BMC Musculoskelet Disord 2019; 20:367. [PMID: 31399083 PMCID: PMC6689168 DOI: 10.1186/s12891-019-2742-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/25/2019] [Indexed: 11/18/2022] Open
Abstract
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. Electronic supplementary material The online version of this article (10.1186/s12891-019-2742-6) contains supplementary material, which is available to authorized users.
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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.
| | - Xiaodong Tang
- 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
| | - Shun Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
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Zhao ZQ, Yan TQ, Guo W, Yang RL, Tang XD, Yang Y. Surgical treatment of primary malignant tumours of the distal tibia: clinical outcome and reconstructive strategies. Bone Joint J 2018; 100-B:1633-1639. [PMID: 30499314 DOI: 10.1302/0301-620x.100b12.bjj-2018-0779.r1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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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Affiliation(s)
- Z-Q Zhao
- Musculoskeletal Tumor Center, Beijing Key Laboratory for Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - T-Q Yan
- Musculoskeletal Tumor Center, Beijing Key Laboratory for Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - W Guo
- Musculoskeletal Tumor Center, Beijing Key Laboratory for Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - R-L Yang
- Musculoskeletal Tumor Center, Beijing Key Laboratory for Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - X-D Tang
- Musculoskeletal Tumor Center, Beijing Key Laboratory for Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
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15
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Zhao Z, Yan T, Guo W, Yang R, Tang X, Wang W. Surgical options and reconstruction strategies for primary bone tumors of distal tibia: A systematic review of complications and functional outcome. J Bone Oncol 2018; 14:100209. [PMID: 30581724 PMCID: PMC6298939 DOI: 10.1016/j.jbo.2018.100209] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/29/2018] [Accepted: 12/01/2018] [Indexed: 01/24/2023] Open
Abstract
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.
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Mizoshiri N, Shirai T, Terauchi R, Tsuchida S, Mori Y, Katsuyama Y, Hayashi D, Oka Y, Kubo T. Limb saving surgery for Ewing's sarcoma of the distal tibia: a case report. BMC Cancer 2018; 18:503. [PMID: 29716532 PMCID: PMC5930845 DOI: 10.1186/s12885-018-4372-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 04/15/2018] [Indexed: 12/23/2022] Open
Abstract
Background Ewing’s sarcoma is a primary malignant tumor of bone occurring mostly in childhood. Few effective reconstruction techniques are available after wide resection of Ewing’s sarcoma at the distal end of the tibia. Reconstruction after wide resection is especially difficult in children, as it is necessary to consider the growth and activity of the lower limbs. Case presentation A 12-year-old Japanese boy had presented with right lower leg pain at age 8 years. Imaging examination showed a bone tumor accompanied by a large extra-skeletal mass in the distal part of his tibia. The tumor was histologically diagnosed as Ewing’s sarcoma. The patient received chemotherapy, followed by wide resection. Reconstruction consisted of a bone transport method involving external fixation of Taylor Spatial Frame. To prevent infection after surgery, the external fixation pin was coated with iodine. One year after surgery, the patient showed poor consolidation of bone, so iliac bone transplantation was performed on the extended bones and docking site of the distal tibia. After 20 months, tibia formation was good. Three years after surgery, there was no evidence of tumor recurrence or metastases; bone fusion was good, and he was able to run. Conclusions The bone transport method is an effective surgical method of reconstruction after wide resection of a bone tumor at the distal end of the tibia, if a pin can be inserted into the distal bone fragment. Coating external fixation pins with iodine may prevent postoperative infection.
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Affiliation(s)
- Naoki Mizoshiri
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
| | - Toshiharu Shirai
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan.
| | - Ryu Terauchi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
| | - Shinji Tsuchida
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
| | - Yuki Mori
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
| | - Yusei Katsuyama
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
| | - Daichi Hayashi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
| | - Yoshinobu Oka
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan
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Vascularized fibular medialization for reconstruction of the tibial defects following tumour excision. INTERNATIONAL ORTHOPAEDICS 2017; 41:2179-2187. [PMID: 28424851 DOI: 10.1007/s00264-017-3474-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/23/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the functional and oncologic results of fibular medialization when used alone as a single-stage reconstructive technique after wide excision of malignant tumours of the proximal, middle, or distal tibia. METHODS Between December 2010 and May 2015, 14 patients (six males and eight females) with primary malignant tumours of the tibia (eight proximal, four diaphyseal, two distal) were treated by wide excision. The mean age of the patients at the time of surgery was 23.2 years (11-38). The fibula was mobilized medially with its vascular pedicle to fill the defect and was fixed by a long plate and screws bypassing the graft. The average size of the defects reconstructed was 19.5 cm (18-22). Patients were evaluated functionally using the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS The mean follow-up period was 31.3 months (range, 17-54). The average time for complete union was 7.6 months (range, 6-9). At final follow-up all patients had fully united grafts; 11 walked without aids. Chest metastases developed in one patient, superficial wound infection in two patients and leg length discrepancy in four patients; one case had LLD of more than 3 cm. The mean MSTS score was 23/30 points (76.5%). The minimum score was 40% (12/30) and the maximum was 90% (27/30). CONCLUSIONS Ipsilateral pedicled vascularized fibular centralisation or medialization is a durable reconstruction for tibial defects after wide excision of bone tumours with an acceptable functional outcome. Stable osteosynthesis is the key to union.
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