This study compared outcomes of 25 patients who underwent limb salvage surgery after excision of a malignant distal tibia tumor with 5 patients who received amputations. For limb salvage, 11 patients received an allograft (Group A), while 14 received a pasteurized autograft with fibula (Group B). Group A had more complications (55%) compared to Group B (14%), with higher nonunion rates and longer time to union. Functional outcomes were better in Group B (mean MSTS score 81%) than Group A (67%). While local recurrence occurred in 3 limb salvage patients, overall survival rates were similar between limb salvage and amputation groups. This study suggests recycled autografts provide better outcomes for distal

1. Surgical Treatment of Primary
Malignant Tumours of the Distal
Tibia
Z-Q. Zhao, T-Q. Yan, W. Guo, R-L. Yang, X-D. Tang, Y. Yang
The Bone and Joint Journal

2. AIMS
• The study aims to compare the clinical outcome of managing 30
patients with a primary malignant tumour of the distal tibia
• 25 were treated by limb salvage surgery and five by amputation.

3. INTRODUCTION
• Primary malignant tumours affecting the distal tibia are rare.1,2
• Following the development of effective chemotherapy and the availability of
modern surgical techniques, between 70% and 95% of patients with a malignant
tumour of the distal tibia can undergo reconstructive surgery.3,4
• Limb salvage has been shown to be associated with acceptable functional outcome
and survival rates when compared with patients who are treated with an
amputation.5-12
• The appropriate methods of reconstruction for patients with a large distal tibial
defect includes various techniques, including massive allograft,6,9,13-16 autograft
using either recycled tumour-bearing bone17,18 or vascularized or non-vascularized
fibula,7,11,19-21 prosthetic replacement,5,8,10 and bone transport,15,20.
• In this study, authors present their experience of 25 patients who underwent
reconstruction after the excision of a malignant tumour of the distal tibia using
either a massive allograft or an autograft arthrodesis of the ankle, and the outcomes
were compared with those of five who underwent amputation.

4. MATERIALS and METHODS
• The 30 patients presented between July 2003 and March 2017
• The inclusion criteria were:
1) Patients with a histologically confirmed primary tumour of the distal tibia without
involvement of the fibula or ankle.
2) Those with and without pulmonary metastases were included.
• Exclusion criteria were:
1) patients with benign or metastatic lesions;
2) those with multicentric osteosarcoma involving the distal tibia;
3) those whose tumour involved the whole tibia;
4) those with involvement of the fibula;
5) those with soft tissue tumours invading the tibia.

5. • Patient no. Age, yrs Gender Diagnosis Stage Resection length, cm Group (reconstruction type) Reconstruction survival time, mths Postoperative follow-up time, mths
• 1 21 Female OS IIB 17 A (with allograft) 151 151
• 2 10 Female OS IIB 9.5 A (with allograft) 17 140
• 3 10 Male ES IIB 8 A (with allograft) 84 84
• 4 12 Male OS III 20 A (with allograft) 11 28
• 5 15 Male OS IIB 11 A (with allograft) 5 31
• 6 31 Female OS IIB 18 A (with allograft) 132 132
• 7 9 Female ES IIB 7 A (with combination of allograft and fibula) 21 134
• 8 20 Male OS IIB 10 A (with combination of allograft and fibula) 62 62
• 9 17 Male OS IIB 18 A (with combination of allograft and fibula) 25 25
• 10 11 Female OS IIB 12 A (with combination of allograft and fibula) 12 17
• 11 8 Male OS IIB 8 A (with combination of allograft and fibula) 22 22
• 12 15 Female ES IIB 13 B (with combination of pasteurized autograft and fibula) 79 79
• 13 15 Female OS IIB 9.5 B (with combination of pasteurized autograft and fibula) 24 24
• 14 13 Male OS IIB 12 B (with combination of pasteurized autograft and fibula) 50 50
• 15 17 Male OS IIB 22 B (with combination of pasteurized autograft and fibula) 31 31
• 16 8 Female ES IIB 14 B (with combination of pasteurized autograft and fibula) 19 19
• 17 11 Male OS IIB 15 B (with combination of pasteurized autograft and fibula) 24 24
• 18 9 Female OS IIB 13.5 B (with combination of pasteurized autograft and fibula) 26 26
• 19 20 Male OS IIB 15 B (double-strut fibula) 48 48
• 20 22 Female OS IIB 15 B (double-strut fibula) 77 77
• 21 22 Male MGCT IIB 7 B (double-strut fibula) 24 24
• 22 45 Male OS IIB 11 B (double-strut fibula) 32 32
• 23 33 Female OS IIB 13 B (double-strut fibula) 15 15
• 24 21 Male OS IIB 14 B (double-strut fibula) 77 77
• 25 17 Male OS IIB 20 B (double-strut fibula) 144 144
• 26 59 Male MFH IIB N/A C N/A 67
• 27 40 Male MFH IIB N/A C N/A 66
• 28 26 Male AD IB N/A C N/A 120
• 29 18 Male OS III N/A C N/A 18
• 30 6 Male ES IIB N/A C N/A 63

6. • All fibular transfers were non-vascularized.
• All patients were initially evaluated using x-rays, MRI, CT, and bone
scans.
• Two cycles of neoadjuvant chemotherapy involving pirarubicin,
cisplatin, high-dose methotrexate, and ifosfamide were given to
patients with an osteosarcoma.
• Chemotherapy for those with Ewing’s sarcoma involved
cyclophosphamide, pirarubicin, vincristine, ifosfamide, and etoposide.
Surgery was undertaken two or three weeks after the completion of
chemotherapy.

7. LIMB SALVAGE
• An anterolateral incision was used for the intra-articular resection of the tumours.
• Tibial osteotomy was performed > 2 cm above the upper margin of the tumour as determined by MRI.
• The mean length of the resection was 13.3 cm (7 to 22).
• Bone marrow samples from the remaining proximal tibia were sent for histological examination.
• Group A includeed 11 patients treated with allograft. Six were treated with a massive allograft. The allograft was soaked
in gentamicin saline at 40°C for 30 minutes, and then the articular surface of the allograft was removed totally. A further
five patients were treated, using a combination of allograft with ipsilateral (four) or contralateral (one) fibula.
• Group B included total of 14 patients treated with an autograft. The tumour-bearing segment in seven patients was
recycled. It was treated by debridement, curettage, and enlargement of the medullary canal and pasteurization in
hypertonic saline (20%) at 65 °C for 30 minutes.24 A combination of pasteurized autograft and fibula was also used in
seven patients.
• A plate and screws were used for fixation at the proximal host-graft junction. The distal junction was fixed by cross
screws in these patients, except for one who was treated with an intramedullary nail.

8. Postoperative radiograph showing the proximal and distal
fixation

9. • Arthrodesis of the ankle was undertaken using double-strut fibular grafts in seven
patients. A contralateral fibular transfer, which was > 2 cm longer than the resected tibia,
was used. One end was introduced into the medulla of the proximal remaining tibia, and
the other end was introduced into a 1 cm notch in the talus. The proximal junction was
fixed using a plate and the distal junction by cross screws in two of these patients.
• Long compression plates and screws were used to bridge the gap between the remaining
tibia and talus in the other five patients.
• The ankle was placed in neutral dorsiflexion with 5° to 10° of valgus and 10° external
rotation. The articular between the talus and lateral malleolus was also fixed with screws
to enhance stability.
• GroupC included five patients who underwent primary amputation.

10. FOLLOW UP
• The patients remained non-weightbearing for three months followed by
partial weight bearing with a brace.
• Full weight-bearing was allowed when fusion was confirmed radiologically.
Union was assessed by two surgeons using serial radiographs.
• A bone scan was used to assess the viability of the grafts.
• Functional outcome was assessed at the final follow-up using MSTS scores.
• The survival following reconstruction was recorded from the time of surgery
with failure of the reconstruction as an endpoint.
• Survival was analyzed from the time of diagnosis to the final follow-up, or
until death.

11. RESULTS
• In group A, four patients (4/11, 36%) achieved union at both proximal and distal junctions.
• One achieved union only proximally, and one achieved union only distally.
• The reconstruction failed in five patients, in whom the functional scores were not obtained.
• Three had local recurrence and underwent amputation; one with a severe deformity of the ankle
requested amputation;
• one with infection underwent revision using a bone cement spacer.
• In group B, 12 patients (86%) achieved union at both junctions (Fig. 2);
• two achieved bone union either proximally or distally.
• The mean time to union proximally in group A and B was 17.2 months (12 to 21) and 11.1 months
(9 to 15), respectively (p = 0.02).
• The mean time to union distally was 16.2 months (12 to 24) and 9.5 months (6 to 12), respectively
(p = 0.04).
• The mean functional MSTS score in group B patients was higher than in group A patients (81% vs
67%; p = 0.06), and similar to that in group C patients (81% vs 82%; p = 0.82).

12. • Three patients (12%) in the limb salvage group had a local recurrence at 5, 11,
and 12 months, respectively, postoperatively, and underwent amputation.
• A total of 12 patients in the whole group (40%) developed pulmonary
metastases, including two who had metastases at presentation.
• Two of these had a solitary lesion that was removed thoracoscopically and had
a disease-free survival.
• The remaining ten died of systematic disease.

13. COMPLICATIONS
• GROUP A
• Of the 11 patients in group A, six (55%) had a major complication, including three with infection and
three with fracture of the graft.
• One patient with chronic infection six months after surgery developed nonunion at both junctions.
The allograft was removed and a spacer was introduced 18 months later. She could walk with
manageable discomfort although she developed talar collapse and a varus deformity of the ankle.
She declined further surgery.
• Another patient had chronic infection with nonunion 11 months after surgery with local recurrence
and underwent amputation.
• A further patient, who had persistent infection and nonunion distally after a myocutaneous sural
rotational flap for soft-tissue cover, declined further surgery.
• Two patients developed a severe varus deformity of the ankle due to fracture of an allograft after 26
and 16 months, respectively, despite iliac bone grafting. One declined further treatment but union
was subsequently achieved. The other was a girl with cosmetic and psychological symptoms who
requested amputation; this was undertaken 21 months postoperatively.
• Another patient had nonunion combined with fracture of an allograft. Bone union was achieved after
autologous iliac crest bone grafting and internal fixation revision two years later.

14. • GROUP B
• Two patients in group B (14%) had complications.
• One had deep infection with proximal nonunion and the internal fixation was removed; this patient achieved
malunion within two years and refused further treatment.
• The other had distal nonunion with a fracture 18 months after surgery; this patient underwent iliac crest bone
grafting and revision fixation, and achieved bone union one year later.
• The incidence of complications for the patients in group A was higher than in those of group B (6/11, 55% vs 2/14,
14%; p = 0.08).
• At the final follow-up, no patient had signs or symptoms of arthritis of the mid-foot or the subtalar joint. Two
patients had limb length discrepancy of < 2 cm, which was well tolerated with an insole.
• GROUP C had no complications

15. DISCUSSION
• Six of 11 patients (55%) in the allograft group developed postoperative complications,
including three whose reconstruction involved allograft alone and three with a
combination of allograft and fibular transfer. This rate is similar to that in previous
studies.6,9,13-15,20
• Recycled pasteurized tumour-bearing bone has several advantages over allograft
including perfect anatomical fit, economical efficiency, the avoidance of disease
transmission, and less immunological reaction.17,18
• Two of seven patients who were treated in this way had complications: one deep
infection combined with nonunion and one stress fracture. Two factors may account for
these rates of complications. First, the allograft we used was from a domestic bone bank.
It was processed using a high dose of gamma irradiation, which may severely interfere
with its biological potential and strength. Second, the use of chemotherapy might
increase the incidence of nonunion.20,28,29

16. • Vascularized ipsilateral fibular grafts were used for arthrodesis in four patients with tibial
bone loss of > 4 cm reported by Bishop et al.19 Arthrodesis was successfully achieved.
• Shalaby et al11 described six patients with an osteosarcoma involving the distal tibia.
They used non-vascularized fibula in three and vascularized fibula in three and tibiotalar
arthrodesis was fixed using an Ilizarov fixator. All patients achieved union although one
had local recurrence.
• Zhang et al21 described a technique for achieving arthrodesis of the ankle using dual
ipsilateral vascularized fibular grafts. The proximal free vascularized ipsilateral fibula was
placed on the medial side of the talus distally and the medial side of the remaining tibia
proximally; the talus was fused with the adjacent double fibula using screws before an
external fixator was applied. All five patients achieved union at a mean of seven months
postoperatively.
• In this study, the contralateral non-vascularized fibula was used. The ipsilateral fibula was
preserved, fusing it to the talus. In this way it can aid weight-bearing. Initial fixation of
the arthrodesis was obtained by plate osteosynthesis bridging the residual tibia and the
talus. According to author, this method is more appropriate than the use of a massive
allograft because soft-tissue cover is easier. Autologous or allogeneic bone chips were
introduced to enhance healing. The fibular transfer becomes hypertrophic when the limb
is loaded. Bone scans showed a greater radionucleotide uptake in the graft, confirming
its viability

17. • The study found that a shorter time was needed and more patients achieved union at
both junctions in group B. This may explain the better mean functional outcome of 81%
in group B compared with 67% in group A.
• However, the outcome was also in the range of MSTS score previously reported after
allo- or autograft arthrodesis of the ankle, respectively.
• Ebeid et al7 evaluated the functional outcome in 13 patients who underwent
reconstruction using an ipsilateral vascularized fibular graft and arthrodesis of the ankle.
The mean functional outcome was 81% (73% to 90%) at a mean of 2.25 years.
• Campanacci et al6 presented eight patients who underwent arthrodesis of the ankle with
bone graft after distal tibial resection. Union was achieved in all and seven patients had a
mean functional MSTS score of 80.4% (53% to 93%) at a mean follow-up of 4.46 years.
• A series of nine distal tibial tumours treated by wide resection and arthrodesis of the
ankle with centralization of the fibula was reported by Kundu et al.23 Two patients had a
nonunion and the mean MSTS score was 76% (57% to 90%), 3.08 years postoperatively.

18. • The local recurrence rate in the current study was 12% (3/25), which is similar to that of
between 10% and 30% in previous studies.9-11,20,25
• The recurrence in two patients might have been related to marginal resection of the
tumour. A poor response to chemotherapy increases the risk of local recurrence.
• Below-knee amputation was performed in five patients.
• Although amputation is associated with significant psychological, physiological, and social
costs to the patient, it still achieves a safe oncological margin and good functional results.
• The mean MSTS score for the patients who underwent amputation was 82%, similar to
that of those who were treated with limb salvage.
• Hence, amputation need only be considered in patients with a poor response to
chemotherapy and those whose tumour involves critical neurovascular structures that
prevent a safe margin being obtained.

19. CONCLUSION
• In conclusion, based on a retrospective review of 30 patients, author
believe that limb salvage is safe and effective in the management of a
malignant distal tibial tumour.
• Reconstruction with autograft and arthrodesis of the ankle can
achieve durable and satisfactory functional results, especially when
using double-strut fibular reconstruction technique, following which
there were no significant complications.
• Long-term follow-up is needed to justify this.
• Below-knee amputation still plays a role when the tumour is adjacent
to the posterior tibial artery and tibial nerve, and when limb salvage
fails.

20. Clinical results and patient-
reported outcomes following
robotic-assisted primary total
knee arthroplasty
Peter Y. Joo, Antonia F. Chen, Jarod Richards, Tsun Y. Law, Kelly Taylor,
Kevin Marchand, Gavin Clark, Dermot Collopy, Robert C. Marchand,
Martin Roche, Michael A. Mont, Arthur L. Malkani

21. AIMS
• The aim of this study was to report patient and clinical outcomes
following robotic-assisted total knee arthroplasty (RA-TKA) at multiple
institutions with a minimum two-year follow-up.

22. METHODS
• This was a multicentre registry study from October 2016 to June 2021
that included 861 primary RA-TKA patients who completed at least
one pre- and postoperative patient-reported outcome measure
(PROM) questionnaire, including Forgotten Joint Score (FJS), Knee
Injury and Osteoarthritis Outcomes Score for Joint Replacement
(KOOS JR), and pain out of 100 points.
• The mean age was 67 years (35 to 86), 452 were male (53%), mean
BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308
(36%) cementless implants.

23. RESULTS
• There were significant improvements in PROMs over time between
preoperative, one- to two-year, and > two-year follow-up, with
• a mean FJS of 17.5 (SD 18.2), 70.2 (SD 27.8), and 76.7 (SD 25.8; p <
0.001);
• mean KOOS JR of 51.6 (SD 11.5), 85.1 (SD 13.8), and 87.9 (SD 13.0; p
< 0.001);
• and mean pain scores of 65.7 (SD 20.4), 13.0 (SD 19.1), and 11.3 (SD
19.9; p < 0.001), respectively.
• There were eight superficial infections (0.9%) and four revisions
(0.5%).

24. CONCLUSION
• RA-TKA demonstrated consistent clinical results across multiple
institutions with excellent PROMs that continued to improve over
time.
• With the ability to achieve target alignment in the coronal, axial, and
sagittal planes and provide intraoperative real-time data to obtain
balanced gaps, RA-TKA demonstrated excellent clinical outcomes and
PROMs in this patient population.

25. THANK YOU