Extensor Function After Medial Gastrocnemius Flap Reconstruction of the Proximal Tibia
Purchase on Springer.com
$39.95 / €34.95 / £29.95*
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.
Reconstruction of the extensor mechanism after resection of the proximal tibia is challenging, and several methods are available. A medial gastrocnemius flap commonly is used, although it may be associated with an extensor lag. This problem also is encountered, although perhaps to a lesser extent, with other techniques for reconstruction of the extensor apparatus. It is not known how such lag develops with time and how it correlates with functional outcome.
We therefore (1) assessed patellar height with time, (2) correlated patellar height with function using the Musculoskeletal Tumor Society (MSTS) score, and (3) correlated patellar height with range of motion (ROM) after medial gastrocnemius flap reconstruction.
Sixteen patients underwent tumor endoprosthesis implantation and extensor apparatus reconstruction between 1997 and 2009 using a medial gastrocnemius flap after sarcoma resection of the proximal tibia. These patients represented 100% of the population for whom we performed extensor mechanism reconstructions during that time. The minimum followup was 2 years (mean, 5 years; range, 2–11 years). Fourteen patients were alive at the time of this study. We used the Blackburne-Peel Index to follow patellar height radiographically with time. Functional outcomes were assessed retrospectively using the MSTS, and ROM was evaluated through active extensor lag and flexion.
Eleven patients had patella alta develop, whereby the maximal patellar height was reached after a mean of 2 years and then stabilized. More normal patellar height was associated with better functional scores, a smaller extensor lag, but less flexion; the mean extensor lag (and flexion) of patients with patella alta was 17° (and 94°) compared with only 4° (and 77°) without.
In our patients patella alta evolved during the first 2 postoperative years. Patella alta is associated with extensor lag, greater flexion, and worse MSTS scores. Surgical fixation of the patellar tendon more distally to its anatomic position or strict postoperative bracing may be advisable.
Level of Evidence
Level IV, clinical cohort study. See the Guidelines for Authors for a complete description of levels of evidence.
- Abboud JA, Patel RV, Donthineni-Rao R, Lackman RD. Proximal tibial segmental prosthetic replacement without the use of muscle flaps. Clin Orthop Relat Res. 2003;414:189–196. CrossRef
- Aparicio G, Abril JC, Calvo E, Alvarez L. Radiologic study of patellar height in Osgood-Schlatter disease. J Pediatr Orthop. 1997;17:63–66.
- Ayerza MA, Aponte-Tinao LA, Abalo E, Muscolo DL. Continuity and function of patellar tendon host-donor suture in tibial allograft. Clin Orthop Relat Res. 2006;450:33–38. CrossRef
- Biau DJ, Dumaine V, Babinet A, Tomeno B, Anract P. Allograft-prosthesis composites after bone tumor resection at the proximal tibia. Clin Orthop Relat Res. 2007;456:211–217. CrossRef
- Bickels J, Wittig JC, Kollender Y, Neff RS, Kellar-Graney K, Meller I, Malawer MM. Reconstruction of the extensor mechanism after proximal tibia endoprosthetic replacement. J Arthroplasty. 2001;16:856–862. CrossRef
- Blackburne JS, Peel TE. A new method of measuring patellar height. J Bone Joint Surg Br, 1977;59:241–242.
- Browne JA, Hanssen AD. Reconstruction of patellar tendon disruption after total knee arthroplasty: results of a new technique utilizing synthetic mesh. J Bone Joint Surg Am. 2011;93:1137–1143. CrossRef
- Caton J. [Method of measuring the height of the patella][in French]. Acta Orthop Belg. 1989;55:385–386.
- Chim H, Tan BK, Tan MH, Tan KC, Song C. Optimizing the use of local muscle flaps for knee megaprosthesis coverage. Ann Plast Surg. 2007;59:398–403. CrossRef
- Classen T, Wegner A, von Knoch M. [Modification of the Blackburne-Peel ratio for improved application in total knee arthroplasty][in German]. Orthopade. 2009;38:1229–1234. CrossRef
- Clohisy DR, Mankin HJ. (1994) Osteoarticular allografts for reconstruction after resection of a musculoskeletal tumor in the proximal end of the tibia. J Bone Joint Surg Am 76:549–554.
- Colangeli M, Donati D, Benedetti MG, Catani F, Gozzi E, Montanari E, Giannini S. Total knee replacement versus osteochondral allograft in proximal tibia bone tumours. Int Orthop. 2007;31:823–829. CrossRef
- Dorfman HD, Czerniak B. Osteosarcoma. In Dorfman HD, Czerniak B, eds. Bone Tumors. St Louis, MO: Mosby; 1998:128–252.
- El-Sherbiny M. Pedicled gastrocnemius flap: clinical application in limb sparing surgical resection of sarcoma around the knee region and popliteal fossa. J Egypt Natl Canc Inst. 2008;20:196–207.
- Elomaa I, Blomqvist CP, Saeter G, Akerman M, Stenwig E, Wiebe T, Bjork O, Alvegard TA. Five-year results in Ewing’s sarcoma: the Scandinavian Sarcoma Group experience with the SSG IX protocol. Eur J Cancer. 2000;36:875–880. CrossRef
- 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;286:241–246.
- ESMO / European Sarcoma Network Working Group. Bone sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2012;23(suppl 7):vii100–109.
- Frey E, Fuchs, B. Resection of the proximal tibia/fibular head, prosthetic megaprosthesis reconstruction combined with gastrocnemius flap. Available at: http://www.sarkomboard.ch/content/resection-proximal-tibiafibular-head-prosthetic-megaprosthesis-reconstruction-combined-gastr. Accessed February 1, 2013.
- Gilbert NF, Yasko AW, Oates SD, Lewis VO, Cannon CP, Lin PP. Allograft-prosthetic composite reconstruction of the proximal part of the tibia: an analysis of the early results. J Bone Joint Surg Am. 2009;91:1646–1656. CrossRef
- Gosheger G, Hillmann A, Lindner N, Rodl R, Hoffmann C, Burger H, Winkelmann W. Soft tissue reconstruction of megaprostheses using a trevira tube. Clin Orthop Relat Res. 2001;393:264–271. CrossRef
- Grelsamer RP, Weinstein CH. Applied biomechanics of the patella. Clin Orthop Relat Res. 2001;389:9–14 . CrossRef
- Grimer RJ, Carter SR, Tillman RM, Sneath RS, Walker PS, Unwin PS, Shewell PC. Endoprosthetic replacement of the proximal tibia. J Bone Joint Surg Br. 1999;81:488–494. CrossRef
- Hillmann A, Hoffmann C, Gosheger G, Krakau H, Winkelmann W. Malignant tumor of the distal part of the femur or the proximal part of the tibia: endoprosthetic replacement or rotationplasty. Functional outcome and quality-of-life measurements. J Bone Joint Surg Am. 1999;81:462–468. CrossRef
- Holzapfel BM, Pilge H, Toepfer A, Jakubietz RG, Gollwitzer H, Rechl H, von Eisenhart-Rothe R, Rudert M. [Proximal tibial replacement and alloplastic reconstruction of the extensor mechanism after bone tumor resection][in German]. Oper Orthop Traumatol. 2012;24:247–262. CrossRef
- Insall J, Salvati E. Patella position in the normal knee joint. Radiology. 1971;101:101–104.
- Jeon DG, Kawai A, Boland P, Healey JH. Algorithm for the surgical treatment of malignant lesions of the proximal tibia. Clin Orthop Relat Res. 1999;358:15–26. CrossRef
- Kendall SJ, Singer GC, Briggs TW, Cannon SR. A functional analysis of massive knee replacement after extra-articular resections of primary bone tumors. J Arthroplasty. 2000;15:754–760. CrossRef
- Meneghini RM, Ritter MA, Pierson JL, Meding JB, Berend ME, Faris PM. The effect of the Insall-Salvati ratio on outcome after total knee arthroplasty. J Arthroplasty. 2006;21(6 suppl 2):116–120. CrossRef
- Miura H, Kawamura H, Nagamine R, Urabe K, Iwamoto Y. Is patellar height really lower after high tibial osteotomy? Fukuoka Igaku Zasshi. 1997;88:261–266 .
- Muscolo DL, Ayerza MA, Farfalli G, Aponte-Tinao LA. Proximal tibia osteoarticular allografts in tumor limb salvage surgery. Clin Orthop Relat Res. 2010;468:1396–1404. CrossRef
- Nguene-Nyemb AG, Huten D, Ropars M. Chronic patellar tendon rupture reconstruction with a semitendinosus autograft. Orthop Traumatol Surg Res. 2011;97:447–450. CrossRef
- Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. Cancer Treat Res. 2009;152:3–13. CrossRef
- Ramseier LE, Dumont CE, Exner GU. Rotationplasty (Borggreve/Van Nes and modifications) as an alternative to amputation in failed reconstructions after resection of tumours around the knee joint. Scand J Plast Reconstr Surg Hand Surg. 2008;42:199–201. CrossRef
- Robert RS, Ottaviani G, Huh WW, Palla S, Jaffe N. Psychosocial and functional outcomes in long-term survivors of osteosarcoma: a comparison of limb-salvage surgery and amputation. Pediatr Blood Cancer. 2010;54:990–999.
- Ruggieri P, Kasimatis G, Errani C, Bosco G, Mercuri M. Desarthrodesis and prosthetic reconstruction of the knee after resection of bone tumors. J Surg Oncol. 2010;102:832–837. CrossRef
- Schiedel F, Probst A, Buller TC, Rodl R. The postoperative patella height: a comparison of additive and subtractive high tibial osteotomy in correcting the genu varum. Arch Orthop Trauma Surg. 2009;129:1271–1277. CrossRef
- Shimose S, Sugita T, Kubo T, Matsuo T, Ochi M. Reconstructed patellar tendon length after proximal tibia prosthetic replacement. Clin Orthop Relat Res. 2005;439:176–180. CrossRef
- Tan PX, Yong BC, Wang J, Huang G, Yin JQ, Zou CY, Xie XB, Tang QL, Shen JN. Analysis of the efficacy and prognosis of limb-salvage surgery for osteosarcoma around the knee. Eur J Surg Oncol. 2012;38:1171–1177. CrossRef
- Titus V, Clayer M. Protecting a patellar ligament reconstruction after proximal tibial resection: a simplified approach. Clin Orthop Relat Res. 2008;466:1749–1754. CrossRef
- Wang TY, Dormans JP, Chang B. Soft-tissue optimization of limb salvage with knee endoprosthesis: the 10-year experience at the Children’s Hospital of Philadelphia. Ann Plast Surg. 2012;69:560–564. CrossRef
- Wunder JS, Leitch K, Griffin AM, Davis AM, Bell RS. Comparison of two methods of reconstruction for primary malignant tumors at the knee: a sequential cohort study. J Surg Oncol. 2001;77:89–99; discussion 100.
- Extensor Function After Medial Gastrocnemius Flap Reconstruction of the Proximal Tibia
Clinical Orthopaedics and Related Research®
Volume 471, Issue 7 , pp 2333-2339
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors