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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 81-83

A case of personalized limb salvage of the distal femur by three-stage distal femoral replacement


Department of Orthopaedic, Laiko General Hospital, University of Athens Medical School, Athens, Greece

Date of Submission05-Apr-2020
Date of Decision23-Apr-2020
Date of Acceptance29-Apr-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Androniki Drakou
Department of Orthopaedic, Laiko General Hospital, University of Athens Medical School, Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_10_20

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  Abstract 


Major distal femur defects involving the knee with underlying osteomyelitis and joint destruction require a staged surgical plan. We describe a case of a 21-year-old patient who suffered high-energy open diaphyseal and articular trauma of his right distal femur. Following radical debridement of bone and soft tissues, we implanted a cement spacer covered by a musculocutaneous flap. Previous tissue scarring did not permit knee function; therefore, we used a 250 ml soft tissue expander to create extra skin cover and we shortened the leg. A custom-made lengthening distal femoral replacement prosthesis was implanted, and the length was gained gradually followed by an intensive full range of motion exercises (0–125). We introduce the combination of first shortening and then lengthening a limb combined with the use of tissue expanders to create a soft tissue functional envelop for a knee prosthesis to work.

Keywords: Lengthening prosthesis, limb salvage, tissue expander


How to cite this article:
Drakou A, Zygogiannis K, Psifis M, Mitrou A. A case of personalized limb salvage of the distal femur by three-stage distal femoral replacement. J Limb Lengthen Reconstr 2020;6:81-3

How to cite this URL:
Drakou A, Zygogiannis K, Psifis M, Mitrou A. A case of personalized limb salvage of the distal femur by three-stage distal femoral replacement. J Limb Lengthen Reconstr [serial online] 2020 [cited 2020 Jul 2];6:81-3. Available from: http://www.jlimblengthrecon.org/text.asp?2020/6/1/81/288560




  Introduction Top


Total knee arthroplasty (TKA) performed with simultaneous distal femoral replacement (DFR) was first designed to treat bone tumors located around the distal femur. It is now increasingly used as a salvage procedure in periprosthetic distal femoral fractures complicated by osteomyelitis.[1] Extensive resection of bone and soft tissues with clear margins is paramount but creates a more significant problem to solve as adequate soft tissue cover is imperative for any joint prosthesis to function. To achieve a tension-free closure of well-perfused tissue, surgeons have used different types of flaps, followed by a variable rate of success.


  Case Report Top


A 21-year-old patient following high-energy open diaphyseal and articular trauma of his right distal femur, 2 years earlier, ended with chronic osteomyelitis with draining sinuses, shortening of 40 mm, a sizeable osteoarticular defect of the anterior femoral condyles, and erosion of the distal femoral condyles. Extensive scarring of the soft tissues and extension contracture with varus of his right knee coexisted.

The patient was informed of all complications, costs, and limited survivorship of DFR but decided to take the risks of limb salvage looking forward to future technological innovations in this area. He could not accept an above-knee amputation at this point.

Initially, we performed radical debridement of the bone and soft tissue, leaving a 160 mm distal femoral defect [Figure 1]a, [Figure 1]b, [Figure 1]c. We used a pedicled rotational lateral gastrocnemius musculocutaneous flap[2] to cover a straight, hand-made, cement spacer. Long-standing soft tissue scarring prevented coverage of an articulated spacer. The spacer later broke, resulting in a total limb length discrepancy (LLD) of 80 mm.
Figure 1: (a) Anteroposterior and lateral X-ray of the right distal femur of the patient at presentation. (b) Frontal view of the surgical specimen with multiple sinuses showing the osteoarticular defect of the anterior condyles. (c) Posterior view of the specimen showing the destruction of the distal condyles

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Six months later, all infection indicators were negative. Loose skin was needed to cover functional knee prosthesis; therefore, we implanted a 250 ml tissue expander at the level of the knee that was gradually fully distended [Figure 2].
Figure 2: Image of the right knee showing the lateral gastrocnemius flap fully healed and the tissue expander in place

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Eight months later, we removed the spacer and the tissue expander and implanted a custom modular MUTARS® Xpand (Implantcast GmbH, Germany) DFR, lengthening prosthesis with a reconstruction length of 175 mm. Intraoperatively, we shortened the bone by 30 mm to achieve an arc of motion of 0°–125° at the knee, ending with an LLD of 55 mm [Figure 3]a and [Figure 3]b. We matched the femoral prosthesis to a custom modular MUTARS® Xpand tibial plateau for a hinged knee. We fixed the individual stems that were hydroxyapatite (HA)-coated employing press fit in both the femoral and tibial medullary canals; the main idea is that when the expanded prosthesis has to be replaced by the definitive one, we do not need to remove the stems.
Figure 3: (a) Three-dimensional computed tomographic images reconstructed following radical debridement and spacer implantation of the right distal femur. (b) Preoperative planning for implant (Xpand) selection based on three-dimensional computed tomographic images reconstructed of the right distal femur

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The surgical wound healed nicely, and at 20 days postoperatively, the patient was able to flex the knee by 125° (range of motion 0–125) [Figure 4]a, [Figure 4]b, [Figure 4]c.
Figure 4: (a) Right knee in extension 2 weeks following surgery (top view). (b) Right knee in flexion 2 weeks following surgery (anteroposterior view). (c) Right knee in flexion at final follow-up (lateral view)

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Lengthening of the prosthesis [Figure 5]a and [Figure 5]b started a month later at various rates, with the primary aim being the preservation of a functional arc of motion. The patient gained 42 mm of length at 7 months and scored a Musculoskeletal Tumor Society score of “29 out of 35” (measuring 12 preoperatively).[3] We decided not to recover the full length because the ankle on the same side was fused and residual shortening enabled walking. At the latest follow-up, at 9 months, he is mobilizing partially weight-bearing up to 40 kg using a cane, and he has an active extension lag of 30° but still improving.
Figure 5: (a) Anteroposterior X-ray of the right distal femur and proximal tibia with the Xpand prosthesis in place lengthened by approximately 30 mm. (b) Lateral X-ray of the right distal femur and proximal tibia with the Xpand prosthesis in place at the final follow-up, lengthened by 42 mm

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We have the patient's consent to publish the case and images protecting his confidentiality.


  Discussion Top


Chronic osteomyelitis necessitates a multidisciplinary approach, involving experts in the field of orthopedic tumor, infection and limb reconstruction surgery, plastic surgery, microbiology, nursing, physiotherapy, and psychology. We discuss herein the stages followed to treat this particular patient.

  • Stage A: Debridement – Curative surgery should ideally involve an extensive resection with clear margins[4]
  • Stage B: Postdebridement reconstruction.


Stage B1: Soft tissue reconstruction – Excision of ischemic tissue and sinuses results in a soft tissue defect that is better reconstructed by direct suturing or tissue transfer at the same sitting as the debridement.[4] For the area of the knee joint, rotational medial, or lateral gastrocnemius, flaps[2] are used.

Stage B2: Skeletal reconstruction –TKA performed with simultaneous DFR was first designed to treat bone tumors located around the distal femur. Over the years, indications have broadened, and this surgery is now increasingly used as a salvage procedure in complex or periprosthetic distal femoral fractures.[1] The introduction of the rotating hinge design as well as of a HA collar[5] at the prosthesis–host bone interface improved the survivorship of the prosthesis. Modular HA stems add to its longevity while permitting customization of the implant to the patients' dimension, as in this case. The survivorship of a DFR for noninfection reasons is reported from 53.3% at 8 years[6] and 77% at 6 years[7] in systematic reviews and large series and may reach 77.1% at 15 years[8] and 78.4% at 18 years[9] in specific small series. Infection complicating DFR may be acute and appear during the first 3 months[6] or late and occur at a mean of 24 months,[7] as shown in a recent systematic review,[7] with a reported incidence of 9%.

Limb salvage offers considerable advantages in terms of function, appearance, and psychological acceptance.[10]

Stage B3: Shortening and then lengthening – In this patient, we applied the concept of shortening the leg to secure adequate soft tissue cover and healing. In addition, we introduced the use of tissue expanders to create a soft tissue envelope loose enough to accommodate the re-established knee position and function, as the expanded prosthesis was growing.

  • Stage C: Replacing the expanding prosthesis with the definitive one. MUTARS® Xpand allows gradual lengthening at any pace, but it is not robust enough and allows restricted weight-bearing up to 40 kg. It has to be replaced by standard MUTARS® components, and this is a drawback that needs serious consideration.[8]


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

We acknowledge Dr. Marios Fragoulis' contribution as a Plastic Surgeon at General Surgery Department of Laiko General Hospital, University of Athens Medical School, Athens, Greece, for this technical support and participation in surgery of raising the gastrocnemius musculocutaneous flap as well as for his advice on the type of tissue expander we used.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
LC Marais, N Ferreira, C Aldous, Prof TLB le Roux. The management of chronic osteomyelitis. South Afr Orthopaed J 2017;13:32-9.  Back to cited text no. 1
    
2.
Walton Z, Armstrong M, Traven S, Leddy L. Pedicled rotational medial and lateral gastrocnemius flaps: Surgical technique. J Am Acad Orthop Surg 2017;25:744-51.  Back to cited text no. 2
    
3.
Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993:241-6.  Back to cited text no. 3
    
4.
McNally M, Nagarajah K. (iv) Osteomyelitis. Orthop Trauma 2010;24:416-29.  Back to cited text no. 4
    
5.
Myers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. Endoprosthetic replacement of the distal femur for bone tumours: Long-term results. J Bone Joint Surg Br 2007;89:521-6.  Back to cited text no. 5
    
6.
Angers-Goulet M, Pelet S, Belzile EL, Bédard M. Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series. Knee 2019;26:1080-7.  Back to cited text no. 6
    
7.
Thornley P, Vicente M, MacDonald A, Evaniew N, Ghert M, Velez R. Causes and frequencies of reoperations after endoprosthetic reconstructions for extremity tumor surgery: A systematic review. Clin Orthop Relat Res 2019;477:894-902.  Back to cited text no. 7
    
8.
Bus MP, van de Sande MA, Fiocco M, Schaap GR, Bramer JA, Dijkstra PD. What are the long-term results of MUTARS® modular endoprostheses for reconstruction of tumor resection of the distal femur and proximal tibia? Clin Orthop Relat Res 2017;475:708-18.  Back to cited text no. 8
    
9.
Batta V, Coathup MJ, Parratt MT, Pollock RC, Aston WJ, Cannon SR, Skinner JA, et al. Uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses: Up to 18 years' follow-up. Bone Joint J 2014;96-B: 263-9.  Back to cited text no. 9
    
10.
Aksnes LH, Bauer HC, Jebsen NL, Follerås G, Allert C, Haugen GS, et al. Limb-sparing surgery preserves more function than amputation. J Bone Joint Surg Br 2008;90:786-94.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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