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).

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

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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.

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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.

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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:
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2. Mirra JM. Bone Tumors: Clinical, Radiologic, and Pathologic
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3. Solomon Louis, Warwick David J, Nayagam Selvadurai.
Tumour. In: Apley’s System of Orthopaedics and Fractures. 8th ed.
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4. Terry Canale S, Daugherty Kay, Jones Linda. Campbell’s
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7. Otis JC, Lane JM, Kroll MA. Energy cost during gait in
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8. Skaliczki G, Antal I, Kiss J, Szalay K, Skaliczki J, SzendrTi M.
Functional outcome and life quality after endoprosthetic
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