J Korean Orthop Assoc.  2019 Feb;54(1):37-44. 10.4055/jkoa.2019.54.1.37.

Limb Salvage Using a Combined Distal Femur and Proximal Tibia Replacement in the Sequelae of an Infected Reconstruction on Either Side of the Knee Joint

• Jeon DG
• Cho WH
• Park H
• Nam H

• KMID: 2438959
• DOI: http://doi.org/10.4055/jkoa.2019.54.1.37

Abstract

PURPOSE
Tumor infiltration around the knee joint or skip metastasis, repeated infection sequelae after tumor prosthesis implantation, regional recurrence, and mechanical failure of the megaprosthesis might require combined distal femur and proximal tibia replacement (CFTR). Among the aforementioned situations, there are few reports on the indication, complications, and implant survival of CFTR in temporarily arthrodesed patients who had a massive bony defect on either side of the knee joint to control infection.
MATERIALS AND METHODS
Thirty-four CFTR patients were reviewed retrospectively and 13 temporary arthrodesed cases switched to CFTR were extracted. All 13 cases had undergone a massive bony resection on either side of the knee joint and temporary arthrodesis state to control the repeated infection. This paper describes the diagnosis, tumor location, number of operations until CFTR, duration from the index operation to CFTR, survival of CFTR, complications, and Musculoskeletal Tumor Society (MSTS) score.
RESULTS
According to Kaplan-Meier plot, the 5- and 10-year survival of CFTR was 69.0%±12.8%, 46.0%±20.7%, respectively. Six (46.2%) of the 13 cases had major complications. Three cases underwent removal of the prosthesis and were converted to arthrodesis due to infection. Two cases underwent partial change of the implant due to loosening and periprosthetic fracture. The remaining case with a deep infection was resolved after extensive debridement. At the final follow-up, the average MSTS score of 10 cases with CFTR was 24.6 (21-27). In contrast, the MSTS score of 3 arthrodesis cases with failed CFTR was 12.3 (12-13). The average range of motion of the 10 CFTR cases was 67° (0°-100°). The mean extension lag of 10 cases was 48° (20°-80°).
CONCLUSION
Although the complication rates is substantial, conversion of an arthrodesed knee to a mobile joint using CFTR in a patient who had a massive bony defect on either side of the knee joint to control infection should be considered. The patient's functional outcome was different from the arthrodesed one. For successful conversion to a mobile joint, thorough the eradication of scar tissue and creating sufficient space for the tumor prosthesis to flex the knee joint up to 60° to 70° without soft tissue tension.

Keyword

osteosarcoma; knee; prosthesis; arthrodesis

MeSH Terms

Arthrodesis
Cicatrix
Debridement
Diagnosis
Extremities*
Femur*
Follow-Up Studies
Humans
Joints
Knee Joint*
Knee*
Limb Salvage*
Neoplasm Metastasis
Osteosarcoma
Periprosthetic Fractures
Prostheses and Implants
Prosthesis Implantation
Range of Motion, Articular
Recurrence
Retrospective Studies
Tibia*

Figure

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  Figure 1 (A) A 9-year-old girl with an osteosarcoma of the proximal tibia underwent a resection of the proximal tibia and was reconstructed with temporary arthrodesis using an intramedullary nail and bone cement (case No. 1). (B, C) At three years after surgery, she showed limb shortening of 5 cm. Limb lengthening using an Ilizarov apparatus was done and the tumor prosthesis was implanted. (D) Despite this, she developed repeated infection. Therefore, resection up to the distal femur and re-arthrodesis was performed. (E) At 9 months after re-arthrodesis, there were no signs of infection and she was switched to combined distal femur and proximal tibia replacement (CFTR). (F) At 29 months after CFTR, loosening of the distal femoral stem was evident. The loosened stem was replaced with a longer stem and massive onlay allograft was performed to supplement the osteoporotic host bone.

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