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Megaprosthetic replacement of knee in a young boy of 14 years

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Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an uncommon procedure in young individuals. Recently, limb conservation surgery for malignant bone tumours like …

Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an uncommon procedure in young individuals. Recently, limb conservation surgery for malignant bone tumours like osteosarcoma around the knee has become a common indication for TKR in young. We report, here a histologically confirmed osteosarcoma in right
proximal tibia of a 14-year-old boy who was managed successfully by limb salvage surgery using Global Modular Replacement System (GMRS, Stryker).

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  • 1. Megaprosthetic replacement of knee in a young boy of 14 years
  • 2. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 3 e2 9 6 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Case Report Megaprosthetic replacement of knee in a young boy of 14 years Raju Vaishya b,*, Md. Zamil Zaidur Rahim a, Vivek Kumar Shrivastava c a Clinical Fellow, Arthroscopy and Arthroplasty, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India b Prof., Sr Consultant, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India c DNB Student, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India article info abstract Article history: Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an Received 25 April 2013 uncommon procedure in young individuals. Recently, limb conservation surgery for ma- Accepted 5 July 2013 lignant bone tumours like osteosarcoma around the knee has become a common indica- Available online 15 August 2013 tion for TKR in young. We report, here a histologically confirmed osteosarcoma in right proximal tibia of a 14-year-old boy who was managed successfully by limb salvage surgery Keywords: Osteosarcoma using Global Modular Replacement System (GMRS, Stryker). Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. Limb salvage Tibia Megaprosthesis 1. Introduction Osteosarcoma is an aggressive malignant neoplasm arising from primitive transformed cells of mesenchymal origin.1 It is the most common histological form of primary bone cancer. This is largely a disease of youth with more than 75% of cases occurring in those less than 25 years of age.2 The management of osteosarcoma in young patients remains a challenging problem and the treatment option may vary from non-operative treatment to operative treatments like amputation and limb conservation. We report a case of 14-year-old male, with grade IIB disease, who was successfully treated by limb conservative surgery. After three cycles neoadjuvant chemotherapy, the tumour was excised in toto and replacement was done by Global Modular Replacement System (GMRS Stryker). 2. Case report A 14-year boy (NT) reported to us with a history of progressive increasing painful swelling in right proximal tibia of six months. It has been associated with restricted knee movement. The swelling was 6 cm  4 cm in size, oval in shape (Fig. 1). It was moderately tender, stony hard and fixed to the bone but overlying skin was free. There was no distal neurovascular deficit. He was investigated with X-ray and MRI * Corresponding author. E-mail address: raju.vaishya@gmail.com (R. Vaishya). 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.07.001
  • 3. 294 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 3 e2 9 6 Fig. 1 e Pre operative photograph showing the tumour below the knee. Fig. 3 e Pre op MRI image of the tumour. which were suggestive of lytic mass in upper end of tibia (Figs. 2 and 3). Core biopsy confirmed the diagnosis of osteosarcoma. Haematological profile revealed anaemia with mild elevation of ESR. PET CT scan revealed FDG avid lytic sclerotic Fig. 2 e Pre operative X-ray of the knee showing tumour involving the upper tibia. destruction in upper tibia with FDG avid soft tissue component and areas of punctuate calcification anteromedially in right upper leg e likely malignant primary bone tumour (Fig. 4). No evidence of FDG avid distant metastases seen. This boy was treated, pre operatively, by three cycles neoadjuvant chemotherapy with Cisplatin and Adriamycin followed by tumour excision and replacement done by Global Modular Replacement System (GMRS). Post operative period was uneventful and he was discharged on 5th post operative day. Fig. 4 e PET CT image of the tumour.
  • 4. 295 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 3 e2 9 6 3. Surgical procedure Under general anaesthesia, medial parapatellar incision was given (which included previous biopsy scar). Wide resection of tumour (99 mm of proximal tibia) done (Fig. 5). Bifurcation of popliteal artery was identified and carefully preserved. Fibular head was left intact. The defect was filled by Global Modular Replacement System (GMRS) (Fig. 6). Tibial prosthesis of a standard size 99 mm was used. Standard size of the prosthesis was used for the femoral component. Tibial and femoral components were fixed with bone cement and joined with a hinge. Stability of prosthesis was checked. Patellar tendon was reattached to the porous coated tibial component of the prosthesis. Haemostasis secured and wound closed in layers keeping a negative suction drain tube in situ. The limb was kept in along leg immobilizer for six weeks, followed by physiotherapy. The post operative X-rays confirmed satisfactory alignment and placement of the prosthesis (Figs. 7 and 8). Histopathology confirmed the diagnosis of malignant osteosarcoma by showing a tumour composed of osteoid with loose oedematous stroma in between and foci of tumour oval and spindle cells (Fig. 9). The excised tumour mass showed 90% tumour cell necrosis and soft tissue margin did not show any evidence of tumour. Rehabilitation and adjuvant chemotherapy were started simultaneously. At 3 months follow up period, the wound has healed with some difficulty, but with complete relief of pain. The patient had achieved 90 flexion range and no evidence of local or distant malignancy at 3 months follow up. 4. Fig. 6 e Replacement with GMRS prosthesis. periosteum and surrounding soft tissues.3 It is slightly more common in male (5.4 per million per year) than in females (4.0 per million per year). It originates more frequently in metaphyseal region of tubular long bone with 42% in femur 19% in tibia 10% in humerus 8% in skull and 8% in pelvis.1 Principles of treatment depend upon age of the patient, site of the tumour, histologic grade and the presence of Discussion The classic osteosarcoma is a highly malignant tumour arising from bone and spreading rapidly outwards to the Fig. 5 e Excised tumour. Fig. 7 e Post op X-ray.
  • 5. 296 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 3 e2 9 6 Fig. 8 e Post op X-ray. Endoprosthetic reconstruction has gained wide popularity for limb-sparing surgery. This involves replacing the removed bone with a metal implant. This obviates the need for bone to bone healing as is necessary with allografts. Megaprosthetic reconstruction has many advantages. It provides immediate stability which allows earlier rehabilitation with immediate full weigh bearing. Most endoprostheses are modular, thus allowing incremental prosthetic replacement in response to the length of resected bone. In addition, improvement in implant materials has greatly increased the durability of modern endoprostheses. They are able to achieve their primary aim of providing long-term function for some patients with relatively low physical demands.6 Patients who had undergone resection and prosthetic knee replacement showed higher self-selected walking velocities and a more efficient gait with regard to oxygen consumption than patients with transfemoral amputations.7 In a study, over 43 patient between 1993 and 2002 malignant tumour around knee region evaluating life quality, it was found that all patients rated the therapy excellent or good, regardless of the type of prosthesis, length or type of resection or tumour site, surgical intervention did not limit their everyday life activities.8 While differences between amputation and limb-sparing procedures do exist, long-term outcomes with regards to patient function and satisfaction appear to be similar. Conflicts of interest All authors have none to declare. references Fig. 9 e Histology appearance. metastasis. Most patients with osteosarcoma around the knee are treated with one of three surgical proceduresdwide resection with prosthetic knee replacement, wide resection with allograft arthrodesis, or a transfemoral amputation.4 Over the past 30 years, limb-sparing procedures have become the standard, mainly due to concomitant advances in chemotherapy and sophisticated imaging techniques. Such advances have made limb salvage possible even after pathologic fracture, previously which was considered as an absolute indication for amputation.5 1. Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. In: Jaffe N, et al., eds. Pediatric and Adolescent Osteosarcoma. New York: Springer; 2009. 2. Mirra JM. Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia: Lea and Febiger; 1989. 3. Solomon Louis, Warwick David J, Nayagam Selvadurai. Tumour. In: Apley’s System of Orthopaedics and Fractures. 8th ed. Arnold; 2001:185e190, 4. 4. Terry Canale S, Daugherty Kay, Jones Linda. Campbell’s Operative Orthopaedics. 11th ed. 566 [chapter 9]. 5. Scully SP, Ghert MA, Zurakowski D, et al. Pathologic fracture in osteosarcoma: prognostic importance and treatment implications. J Bone Joint Surg. 2002;84A:49. 6. Peh Khee T, Mann Hong T. Functional outcome study of megaendoprosthetic reconstruction in limbs with bone tumour surgery. Ann Acad Med Singap. 2009;38:192e196. 7. Otis JC, Lane JM, Kroll MA. Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above-the-knee amputation. J Bone Joint Surg. 1985;67A:606. 8. Skaliczki G, Antal I, Kiss J, Szalay K, Skaliczki J, SzendrTi M. Functional outcome and life quality after endoprosthetic reconstruction following malignant tumours around the knee. Int Orthop (SICOT). 2005;29:174e178.
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