PMC7298547_01
Clinical Picture After Chemotherapy.
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The range of movement of both of the knee and ankle was normal (Fig. 1).
A. Cruris xray showed a mixed lytic and blastic lesion. B. Thorax xray showed no sign of metastasis.
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Plain radiography suggested mixed lytic and blastic bony lesion in metaphyseal area of proximal tibia, with ill-defined margin, wide transitional zone, periosteal reaction, matrix osteoid and also soft tissue involvement (Fig. 2a). Plain radiography of chest showed no sign of pulmonary metastasis (Fig. 2b).
MRI showed a heterogenous mass in epiphysis extending to diaphysis of tibia, 16 cm from tibiofemoral joint, without neurovascular bundle involvement.
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Contrast-enhanced magnetic resonance imaging (MRI) showed heterogeneous mass and no neurovascular bundle involvement (Fig. 3).
A. Patellar tendon preservation. B. Medial collateral ligament preservation.
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Intraoperatively, we managed to perform wide excision, while preserving some part of patellar tendon, medial collateral ligament, and cruciate ligament (Fig. 4).
A. Tumor exposed. B. Bone defect 19 cm after tumor removal. C. Gross pathology of the tumor.
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We excised the tumor and then we measured the bone defect is 19 cm from joint line (Fig. 5).
Construction of The Implant. We drilled the insert component of the tibial to make a hole later for suturing the remaining ACL and PCL. We added K-nail below the stem of base plate tibia and combined it with proximal tibial plate using cerclage wire.
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We put the nail intramedullary to distal remaining bone (Fig. 6).
Post patellar tendon and MCL reconstruction. We sutured the remaining patellar tendon, MCL, ACL and PCL using polyester suture to the Mesh.
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We reconstructed the cruciate ligament through the insert and tied to the mesh and also we tied all the medial collateral ligament and the remaining patellar tendon to the mesh (Fig. 7).
Final result with medial gastrocnemius flap.
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We added medial gastrocnemius flap to add coverage of soft tissue covering the implants (Fig. 8).
Post operative xray.
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We put a posterior splint directly after operation (Fig. 9).
Histopathology feature showed osteosarcoma post neoadjuvant chemotherapy with 75% necrosis of the tumor cell consisted with HUVOS 2. (H&E, 400x).
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Subesquently, we confirmed the histopathology result for HUVOS result (Fig. 10) and continued with chemotherapy adjuvant for another 5 cycles with regiments of iphosphamide, cisplatin and adriamycin.
Clinical picture showed a lump on previous scar.
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The lump size was 2 x 2 x 2 cm with hard consistency and pain visual analogue scale 2-3 (Fig. 11).
A. Tumor exposed. B. Gross pathology of the tumor.
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Then, we did excision of the mass and it came out the result was osteosarcoma (Fig. 12, Fig. 13).
Clinical outcome after 1 year of surgery. Patient can walk without any additional aid and no pain. Flexion and extension 10-50 degrees.
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The leg length discrepancy was approximately 1 cm, her knee flexion-extension range of motion was 10 to 50 degrees within stable varus valgus test, motoric strength 4, and the MSTS score was 21 (Fig. 14).