D728587fff2d87201eae0a158507d814 2

Ewing sarcoma of the tibia

Ewing sarcoma of the tibia. A 2 year and six month old patient had pain in the proximal region of the right tibia associated with an increase in volume for eleven months. In the requested radiographs, a poorly delimited intra-osseous lesion was observed, with a radio-dense appearance, suggesting a sclerotic lesion. The possibility of bone neoplasia was considered and additional tests were carried out for diagnosis and staging.
Figura 1: Radiografia da perna direita frente, com alteração na região metafisária proximal da tibia
Figure 1: Radiograph of the front right leg, with changes in the proximal metaphyseal region of the tibia
Figura 2: Radiografia da perna em perfil, lesão condensante na metáfise proximal da tíbia.
Figure 2: Radiograph of the leg in profile, condensing lesion in the proximal metaphysis of the tibia.
Figura 3: Cintilografia óssea vista de frente, evidenciando a captação na região da tíbia proximal direita.
Figure 3: Bone scintigraphy seen from the front, showing uptake in the region of the right proximal tibia.
Figura 4: Cintilografia, vista posterir, evidenciando a captação na região proximal da tibia direita.
Figure 4: Scintigraphy, posterior view, showing uptake in the proximal region of the right tibia.
Figura 5: PET-CT, com intensa captacão na região metafisária da tíbia direita.
Figure 5: PET-CT, with intense uptake in the metaphyseal region of the right tibia.
Figura 6: PET-CT, evidenciando o local da lesão.
Figure 6: PET-CT, showing the location of the injury.
Figura 7: PET-CT assinalando lesão secundária no tórax.
Figure 7: PET-CT showing a secondary lesion in the chest.
Figura 8: RM cor T1, apresenta lesão na região metafisária proximal da tíbia direita, sem sinal de comprometimento da epífise.
Figure 8: T1 color MRI, showing a lesion in the proximal metaphyseal region of the right tibia, with no sign of involvement of the epiphysis.
Figura 9: RM sag T1, com lesão meta-diafisária na tíbia.
Figure 9: T1 sag MRI, with meta-diaphyseal injury in the tibia.
Figura 10: RM axial T1 com alteração da medular óssea, devido à lesão neoplásica.
Figure 10: Axial T1 MRI with changes in the bone marrow, due to the neoplastic lesion.
Figura 11: RM axial T1, com alteração do sinal da medular e extensão extra óssea da lesão tumoral.
Figure 11: Axial T1 MRI, with changes in the medullary signal and extra-osseous extension of the tumor lesion.
Figura 12: RM cor stir, lesão metafisária com epífise sem sinais de tumor.
Figure 12: Color stir MRI, metaphyseal lesion with epiphysis without signs of tumor.
Figura 13: RM sag ffe, exibindo a lesão metafisária. A epífise da tíbia não apresenta sinal de alteração.
Figure 13: Sag ffe MRI, showing the metaphyseal lesion. The tibial epiphysis shows no sign of change.
Figura 8: RM cor T1, apresenta lesão na região metafisária proximal da tíbia direita, sem sinal de comprometimento da epífise.
Figure 8: T1 color MRI, showing a lesion in the proximal metaphyseal region of the right tibia, with no sign of involvement of the epiphysis.
Figura 9: RM sag T1, com lesão meta-diafisária na tíbia.
Figure 9: T1 sag MRI, with meta-diaphyseal injury in the tibia.
Figura 10: RM axial T1 com alteração da medular óssea, devido à lesão neoplásica.
Figure 10: Axial T1 MRI with changes in the bone marrow, due to the neoplastic lesion.
The patient underwent a biopsy which revealed Ewing’s sarcoma in the proximal metaphyseal region of the right tibia. The patient underwent neoadjuvant chemotherapy treatment. The proposed surgical treatment, for local control of the tumor, was resection of the lesion, performing trans-epiphyseal osteotomy in the proximal epiphysis and reconstruction with the autotransplantation technique of the ipsi-lateral fibula. with its epiphysis and its growth cartilage. Resection of the proximal region of the tibia, in such a young patient, leads to loss of growth potential of the tibial physis, causing great dysmetria between the lower limbs in adulthood. This technique aims to allow the growth cartilage of the fibula to replace the “physis” of the tibia, which has been resected. We therefore perform auto-transplantation of the fibula to the resected region of the tibia, bringing this bone segment with its own vascularization, maintaining the growth cartilage of the proximal region of the fibula and its growth potential. This set is stabilized by the sliding fixing device developed by us, which consists of two plates designed especially for this case. These two pieces are connected by a trapezoidal rail, which guarantees stability between the two components and at the same time allows longitudinal sliding, so that the bone growth produced by the fibular physis transposed to the tibia is not blocked.
Figura 17: Dispositivo de fixação interna extensivel, seguimento proximal, vista de perfil. Plataforma para suporte da epífise tibial, aba para dois parafusos epifisários e haste curvilínea moldada na tíbia com final reto para permitir deslizamento.
Figure 17: Extendable internal fixation device, proximal segment, profile view. Platform to support the tibial epiphysis, flap for two epiphyseal screws and curvilinear rod molded into the tibia with a straight end to allow sliding.
Figura 18: Dispositivo de fixação interna extensiva, seguimento distal, com três orifícios para fixação na diafíse da tíbia e canaleta para encaixe da parte proximal, propiciando a estabilização das partes e permitindo o deslizamento.
Figure 18: Extensive internal fixation device, distal segment, with three holes for fixation in the tibial diaphysis and channel for fitting the proximal part, providing stabilization of the parts and allowing sliding.
Figura 19: Dispositivo de fixação interna extensível, parte proximal e distal, vista de perfil.
Figure 19: Extendable internal fixation device, proximal and distal part, profile view.
Figura 20: Dispositivo de fixação interna extensível, parte proximal , vista de frente com dois orifícios para fixação.
Figure 20: Extendable internal fixation device, proximal part, front view with two holes for fixation.
Figura 21: Dispositivo de fixação interna extensível, parte distal, vista de frente com três orifícios para fixação distal.
Figure 21: Extendable internal fixation device, distal part, front view with three holes for distal fixation.
Figura 22: Dispositivo de fixação interna extensível deslizante, parte proximal e distal, vista de frente, com dois orfícios na parte proximal e três orifícios para fixação distal.
Figure 22: Sliding extendable internal fixation device, proximal and distal part, viewed from the front, with two holes in the proximal part and three holes for distal fixation.
Figura 23: Planejamento cirúrgico, vista de frente evidenciando a posição das placas, e a fixação dos dois parafusos proximais e os três distais.
Figure 23: Surgical planning, front view showing the position of the plates, and the fixation of the two proximal and three distal screws.
Figura 24: Planejamento cirúrgico, vista de perfil, evidenciando a posição das placas, e a fixação dos dois parafusos proximais e os três
Figure 24: Surgical planning, profile view, showing the position of the plates, and the fixation of the two proximal screws and the three
Figura 25: Planejamento cirúrgico, assinalando a posição em que a placa ficará na perna do paciente.
Figure 25: Surgical planning, marking the position in which the plate will be placed on the patient’s leg.

Video 1 : Demonstration of the sliding plate mechanism, which runs in a trapezoidal fitting similar to that of a lathe.

In December 2006, the patient underwent surgery to resect the proximal metaphyseal segment of the tibia, including the growth plate, and self-transplantation of the growth cartilage of the proximal segment of the fibula, through transfer to the tibia, without microsurgery.

SURGICAL TECHNIQUE:

The patient is positioned in a horizontal supine position. A single, curved access route is used, starting above the proximal tibio-fibular joint, descending and curving medially towards the crest of the tibia and continuing distally along the internal surface of the tibia, until a few centimeters below the place where fibular osteotomy will be performed.

Figura 26: Planejamento para a incisão, prevendo-se a ressecção do trajeto da biópsia em bloco com a peça cirúrgica.
Figure 26: Planning for the incision, foreseeing the resection of the biopsy path en bloc with the surgical specimen.
Figura 27: Incisão cirúrgica.
Figure 27: Surgical incision.
Figura 28: Incisão cirúrgica na região do joelho até próximo ao tornozelo.
Figure 28: Surgical incision in the region from the knee to close to the ankle.
Figura 29: Dissecção do sub-cutâneo por sobre o periósteo, para exposição da tíbia, medialmente.
Figure 29: Dissection of the subcutaneous tissue above the periosteum, to expose the tibia, medially.
The tibialis anterior muscle is exposed, the perimysium is opened and the muscle is moved laterally, leaving the inner layer of this perimysium adhered to the periosteum, aiming to preserve the oncological resection margin of the tibia
Figura 30: Liberação do sub-cutâneo por sobre o periósteo, na região proximal.
Figure 30: Release of the subcutaneous layer over the periosteum, in the proximal region.
Figura 31: Liberação do sub-cutâneo por sobre o tendão patelar e patela.
Figure 31: Release of the subcutaneous tissue over the patellar tendon and patella.
Figura 32: Liberação do sub-cutâneo por sobre a pata de ganso e expondo-se a região póstero-medial da perna.
Figure 32: Release of the subcutaneous tissue over the pes anserine and exposing the posteromedial region of the leg.
Figura 33: Isolamento e liberação da pata de ganso.
Figure 33: Isolation and release of the pes anserinus.
Figura 34: Desinserção da pata de ganso.
Figure 34: Detachment of the pes anserinus.
Figura 35: Liberação da face medial da tíbia que será ressecada, por sobre o periósteo.
Figure 35: Release of the medial face of the tibia that will be resected, above the periosteum.
Figura 36: Visualização da dissecção cirúrgica com cuidadosa hemostasia.
Figure 36: Visualization of surgical dissection with careful hemostasis.
Figura 37: Em detalhe, seta amarela, o segmento de pele e trajeto da biópsia que será ressecado em bloco com o tumor. As setas azuis assinalam a ausência de torniquete na coxa. Não se utiliza o garroteamento do membro.
Figure 37: In detail, yellow arrow, the skin segment and biopsy path that will be resected en bloc with the tumor. The blue arrows indicate the absence of a tourniquet on the thigh. Garrotting of the member is not used.
Figura 38: abertura do perimísio do tibial anterior proximalmente.
Figure 38: opening of the perimysium of the tibialis anterior proximally.
Figura 39: A abertura do perimísio do músculo tibial anterior é realizada a cerca de 5 mm lateralmente à crista da tíbia.
Figure 39: The opening of the perimysium of the tibialis anterior muscle is performed approximately 5 mm lateral to the tibial crest.
Figura 40: Todo o acesso para o descolamento do músculo tibial anterior esta feito.
Figure 40: All access for detachment of the anterior tibialis muscle has been completed.
Figura 41: Exposição do ligamento colateral lateral.
Figure 41: Exposure of the lateral collateral ligament.
The neck of the fibula is identified and the common peroneal nerve isolated. The proximal tibiofibular joint is approached and the joint capsule, along with the anterior ligament, posterior ligament, arcuate popliteal ligament, fibular collateral ligament, and the tendon of the biceps femoris muscle are released.
Figura 42: Isolamento do ligamento colateral lateral.
Figure 42: Isolation of the lateral collateral ligament.
Figura 43: Ligamento colateral lateral seccionado.
Figure 43: Sectioned lateral collateral ligament.
Figura 44: Dissecção do músculo tibial anterior, deixando o perimísio e periósteo da tíbia aderidos ao segmento que será ressecado, como margem oncológica.
Figure 44: Dissection of the anterior tibial muscle, leaving the perimysium and periosteum of the tibia attached to the segment that will be resected, as the oncological margin.
Figura 45: Liberção do nervo ciático popliteo externo.
Figure 45: Release of the external popliteal sciatic nerve.
Figura 46: Liberação da articulação fibulo-tibial proximal.
Figure 46: Release of the proximal fibulotibial joint.
Figura 47: Dissecção do trajeto da biópsia.
Figure 47: Dissection of the biopsy path.
Figura 48: Passagem de fio de kirchnner para identificação da interlinha articular do joelho, fascilitando a mensuração do segmento a ser ressecado.
Figure 48: Passing a Kirchnner wire to identify the joint joint line of the knee, facilitating the measurement of the segment to be resected.
Figura 49: Isolamento do ligamento patelar, mantendo-o inserido na epífise tibial.
Figure 49: Isolation of the patellar ligament, keeping it inserted into the tibial epiphysis.
Figura 50: Delimitação da linha de osteotomia, preservando o ligamento patelar inserido na epífise tibial.
Figure 50: Delimitation of the osteotomy line, preserving the patellar ligament inserted into the tibial epiphysis.
Figura 51: Delimitação do plano de osteotomia, infra-meniscal na tíbia.
Figure 51: Delimitation of the osteotomy plane, infra-meniscal on the tibia.
Figura 52: Liberação do músculo solear, descolando-o com uma ¨pipoca¨de gase.
Figure 52: Release of the soleus muscle, detaching it with a “popcorn” of gas.
Figura 53: Marcação do segmento de tíbia, a ser ressecado, com margem de segurança na região distal.
Figure 53: Marking of the tibia segment to be resected, with a safety margin in the distal region.
The proximal epiphysis of the tibia together with the anterior tuberosity are isolated from the metaphyseal region. A Kirschner wire is passed through this epiphysis, horizontally, at the point where the proximal fixation will be made and the position of the plate is then checked.
Figura 54: Passagem de fio de Kirschner inframeniscal, tangenciando a superfície articular da tíbia.
Figure 54: Inframeniscal Kirschner wire passage, touching the articular surface of the tibia.
Figura 55: Fio de Kirschner posicionado para referencia e orientação no posicionamento da placa.
Figure 55: Kirschner wire positioned for reference and guidance when positioning the plate.
Figura 56: O segmento proximal do dispositivo de fixação interna extensível é posicionado logo abaixo do fio,
Figure 56: The proximal segment of the extendable internal fixation device is positioned just below the wire,
Figura 57: Verificação da altura correta para colocação da placa, proximalmente
Figure 57: Checking the correct height for placing the plate, proximally
Figura 58: Estudo do posicionamento do dispositivo acoplado e verificação do alinhamento no plano lateral.
Figure 58: Study of the positioning of the coupled device and verification of alignment in the lateral plane.
Figura 59: Realização prévia, com broca, dos orifícios para passagem dos parafusos epifisários.
Figure 59: Previously creating, with a drill, the holes to pass the epiphyseal screws.
After measuring the segment to be resected, respecting the oncological margin, a distal osteotomy of the tibia is performed, in the diaphyseal region. The posterior muscles, from the proximal segment, are disinserted to the epiphyseal region of the tibia, proximally. The tibial epiphysis is then separated from the tumor by transepiphyseal osteotomy, preserving as much of the epiphyseal bone with its articular cartilage as possible and the tumor is resected.
Figura 60: Osteotomia com a Serra de Gigle.
Figure 60: Osteotomy with the Gigle Saw.
Figura 61: Após a osteotomia, complementa-se a liberação das estruturas moles póstero-laterais que ainda estiverem inseridas.
Figure 61: After the osteotomy, the release of the posterolateral soft structures that are still attached is completed.
Figura 62: Dissecção do feixa vascular e liberação da articulação tibio-fibular proximal.
Figure 62: Dissection of the vascular bundle and release of the proximal tibio-fibular joint.
Figura 63: Disseção cuidadosa dos vasos tibial anterior e ramos recorrentes, que nutrem a epífise fibular proximal.
Figure 63: Careful dissection of the anterior tibial vessels and recurrent branches, which nourish the proximal fibular epiphysis.
Figura 64: Osteotomia da cortical tibial, com osteótomo fino e estreito, delineando o plano de corte.
Figure 64: Osteotomy of the tibial cortex, with a thin and narrow osteotome, outlining the cutting plane.
Figura 65: Após a corticotomia circunferencial completamos a osteotomia transfisária na tuberosidade anterior e transepifisária no restante da tíbia, com formão curvo e mais largo.
Figure 65: After the circumferential corticotomy, we completed the transphyseal osteotomy in the anterior tuberosity and transepiphyseal osteotomy in the rest of the tibia, with a curved and wider chisel.
Figura 66: Com o osteótomo curvo vamos delicadamente completando o corte na região proximal da tíbia, respeitando a anatomia da epífise tibial de forma a preservar o ligamento patelar inserido nela.
Figure 66: With the curved osteotome we delicately complete the cut in the proximal region of the tibia, respecting the anatomy of the tibial epiphysis in order to preserve the patellar ligament inserted into it.
Figura 67: Liberação circunferencial da epífise fibular proximal, para remoção da cartilagem articular da fíbula, propiciando a consolidação da epífise fibular com a epífise tibial.
Figure 67: Circumferential release of the proximal fibular epiphysis, to remove the articular cartilage of the fibula, providing consolidation of the fibular epiphysis with the tibial epiphysis.
Video 2 : After release, the cartilage of the fibular epiphysis must be removed, exposing the ossification nucleus to consolidate with the bone tissue of the tibial epiphysis. This film, exemplifying the removal of the fibula’s articular cartilage, is from another patient.
To replace the bone defect created with the resection of the tibial segment, containing the tumor, we used the proximal segment of the ipsilateral fibula for reconstruction. This is isolated from the tibiofibular joint and the lateral collateral ligament. A small deperiostization is performed, of one to two centimeters, at the height where the osteotomy will be made in the fibular shaft (figure 69). After the osteotomy, this deperiostized part will be embedded within the medullary shaft of the tibia.
Figura 68: Identificação da artéria e veia tibial anterior recorrente, que irriga a epífise fibular proximal.
Figure 68: Identification of the recurrent anterior tibial artery and vein, which irrigates the proximal fibular epiphysis.
Figura 69: Desperiostização do segmento distal da fíbula para encavilhamento na tíbia.
Figure 69: Desperiostization of the distal segment of the fibula for nailing in the tibia.
Figura 70: Alargamento do canal medular da tíbia, para fascilitar o encavilhamento.
Figure 70: Widening of the medullary canal of the tibia, to facilitate nailing.
Figura 71: Manobra para encavilhamento da fíbula no canal medular da tíbia, distalmente.
Figure 71: Maneuver to anchor the fibula in the medullary canal of the tibia, distally.
Figura 72: Tentativa de encavilhamento da fíbula no canal medular da tíbia.
Figure 72: Attempt to nail the fibula into the medullary canal of the tibia.
Figura 73: Afilamento da fíbula através de frezagem para diminuir a espessura fibular, possibilitando a sua introdução no canal medular tibial.
Figure 73: Fibula thinning through milling to reduce fibular thickness, enabling its introduction into the tibial medullary canal.
Figura 74: Segmento fibular afilado e com diâmetro preparado para o encavilhamento.
Figure 74: Tapered fibular segment with diameter prepared for nailing.
Figura 75: A fíbula é encavilhada cuidadosamente dentro do canal medular da tíbia.
Figure 75: The fibula is carefully doweled into the medullary canal of the tibia.
Next, the proximal segment of the fibula is prepared for transposition, together with all the muscles and its nutrient arteries, to the central region under the remaining tibial epiphysis. The fibular collateral ligament is inserted into the tibial periosteum to fix this position.
Figura 76: Fíbula encavilhada. Preparação para o posicionamento da epífise fibular, com a sua fise de crescimento, sob o a parte mais central da epífise tibial.
Figure 76: Nailed fibula. Preparation for positioning the fibular epiphysis, with its growth physis, under the most central part of the tibial epiphysis.
Figura 77: Cabeça da fíbula ainda com a cartilagem articular, que precisa ser ressecada para permitir a consolidação entre a epífise tibial e a epífise fibular.
Figure 77: Head of the fibula still with the articular cartilage, which needs to be resected to allow consolidation between the tibial epiphysis and the fibular epiphysis.
Stabilization of the reconstruction is performed using Baptista’s extensible internal fixation device, placed on the medial side of the leg, which is previously custom-made for each case. The proximal and distal segments of this device are fixed with screws and these segments are connected to each other by a trapezoidal fitting that allows sliding between them, as occurs in a mechanical lathe.
Figura 80: Realização do segundo orifício proximal e colocação do parafuso.
Figure 78: Creation of the thread channel for the proximal screw.
Figura 79: Fixação do segmento proximal com parafuso.
Figure 79: Fixation of the proximal segment with a screw.
Figura 80: Realização do segundo orifício proximal e colocação do parafuso.
Figure 80: Making the second proximal hole and placing the screw.
Figura 81: Realização do primeiro orifício epifisário para passagem de fio de Ethibond, para fixação da posição sob o centro da epífise tibial.
Figure 81: Making the first epiphyseal hole to pass the Ethibond thread, to fix the position under the center of the tibial epiphysis.
Figura 82: Realização do segundo orifício epifisário para passagem de fio de Ethibond, para fixação da posição sob o centro da epífise tibial.
Figure 82: Making the second epiphyseal hole to pass the Ethibond thread, to fix the position under the center of the tibial epiphysis.
Figura 83: Sutura do coto do ligamento colateral lateral na porção lateral do ligamento patelar.
Figure 83: Suturing the stump of the lateral collateral ligament to the lateral portion of the patellar ligament.
Figura 84: Sutura e fechamento dos tecidos moles na região antero-lateral proximal do joelho.
Figure 84: Suturing and closing the soft tissues in the proximal anterolateral region of the knee.
Figura 85: aproximação da fascia lata com as estruturas de tecidos moles inseridas na epífise fibular.
Figure 85: approximation of the fascia lata with the soft tissue structures inserted into the fibular epiphysis.
Figura 86: Aproximação do sub-cutâneo.
Figure 86: Approximation of the subcutaneous tissue.
Figura 87: Finalização do fechamento antero-lateral do joelho.
Figure 87: Completion of the anterolateral closure of the knee.
Figura 88: Reposicionamento da placa na região distal da tíbia, e perfuração para passagem do parafuso para fixação.
Figure 88: Repositioning the plate in the distal region of the tibia, and drilling to pass the screw for fixation.
Figura 89: Passagem do primeiro parafuso na placa, na região distal da tíbia.
Figure 89: Passage of the first screw into the plate, in the distal region of the tibia.
Figura 90: Passagem do segundo parafuso na placa, na região distal da tíbia.
Figure 90: Passage of the second screw in the plate, in the distal region of the tibia.
Subsequently, hemostasis is performed, the reinsertion of the soft tissues is completed, an aspiration drain is placed and the subcutaneous tissue and skin are closed.
Figura 91: Passagem do terceiro parafuso na placa, na região distal da tíbia.
Figure 91: Passage of the third screw in the plate, in the distal region of the tibia.
Figura 92: Cobertura completa da região antero lateral.
Figure 92: Complete coverage of the anterolateral region.
Figura 93: Reconstrução finalizada. Transferencia do segmento proximal da fíbula com sua cartilagem de crescimento e osteossíntese com o dispositivo de fixação interna extensível.
Figure 93: Completed reconstruction. Transfer of the proximal segment of the fibula with its growth cartilage and osteosynthesis with the extensible internal fixation device.
Figura 94: Visualização da fixação final da placa e dos parafusos, vista lateral.
Figure 94: Visualization of the final fixation of the plate and screws, side view.
Figura 95: Reinserção dos tendões da pata de ganso.
Figure 95: Reinsertion of the pes anserinus tendons.
Figura 96: Fechamente e cobertura da região antero-medial do joelho.
Figure 96: Closure and coverage of the anteromedial region of the knee.
Figura 97: Cobertura da reconstrução com o músculo tibial anterior.
Figure 97: Coverage of the reconstruction with the anterior tibialis muscle.
Figura 98: Aspecto final da sutura.
Figure 98: Final appearance of the suture.
Figura 99: Curativo e colocação de órtese.
Figure 99: Dressing and orthosis placement.
After dressing, the operated limb is placed in an orthosis which was also previously made, custom-made, for this patient. This orthosis is used as an external support, for protection, until the fibula consolidates and increases its thickness, to be able to support the total load.
Figura 100: Peça ressecada, com o trajeto da biópsia, osteotomia curvelínea proximal, transfisária e parte transepifisária, face anterior.
Figure 100: Resected specimen, with the biopsy path, proximal curvelinear osteotomy, transphyseal and transepiphyseal part, anterior surface.
Figura 101: Peça ressecada, face posterior.
Figure 101: Resected piece, back side.
Figura 102: Peça ressecada, face lateral.
Figure 102: Dried piece, side face.
Figura 103: Peça ressecada, face medial.
Figure 103: Resected piece, medial side.
Figura 104: Peça com o trajeto da biópsia ressecado, osteotomia curvelínea, transfisária na tuberosidade tibial e transepifisária no restante.
Figure 104: Piece with the biopsy path resected, curvelinear osteotomy, transphyseal in the tibial tuberosity and transepiphyseal in the remainder.
Figura 105: Detalhe da ressecção transepifisária.
Figure 105: Detail of the transepiphyseal resection.
Figura 106: Peça ressecada e dividida em duas partes, para estudo anatomo patológico do gráu de necrose e da margem oncológica da ressecção. Em destaque o trajeto da biópsia ressecado em bloco com a lesão.
Figure 106: Piece resected and divided into two parts, for anatomical pathological study of the degree of necrosis and the oncological margin of the resection. Highlighted is the biopsy path resected en bloc with the lesion.
The immediate post-operative radiographs detail the resected metaphyseal segment of the tibia, including the growth plate, and the reconstruction carried out, with auto-transplantation of the growth cartilage from the fibula to the tibia, through transfer thereof, without the need for microsurgery. and using the sliding plate, designed especially for this patient, figures 108 to 111.
Figura 107: Radiografia do pós operatório da peça ressecada, frente.
Figure 107: Post-operative radiograph of the resected specimen, front.
Figura 108: Radiografia do pós operatório da peça ressecada, perfil, destacando a retirada da cartilagem de crescimento.
Figure 108: Post-operative radiograph of the resected piece, profile, highlighting the removal of the growth cartilage.
Figura 109: Radiografia da perna operada e reconstruida com o auto transplante de cartilagem de crescimento, osteossíntese com o dispositivo de fixação interna extensível.
Figure 109: Radiograph of the operated and reconstructed leg with auto transplantation of growth cartilage, osteosynthesis with the extensible internal fixation device.
Figura 110: Radiografia pós operatória da perna fixada com o dispositivo, face de perfil.
Figure 110: Post-operative radiograph of the leg fixed with the device, profile view.
The patient restarts chemotherapy three weeks after surgery. Return to the office for reevaluation, six weeks after surgery.

Video 3: On 02/12/2007, patient showing good movement of his right leg, six weeks after surgery.

After surgery, the leg was kept in an orthosis, specially made for the case, and weight-bearing began in the third month after surgery. Over the following eight months, growth of approximately 0.3 cm of the transposed fibula was observed. There was distal bone consolidation of the transposed fibula with the tibia, together with initial hypertrophy of the fibula that could be radiographically proven. The patient continued with adjuvant chemotherapy and began walking without protection five months after surgery. This is possible due to the stability provided by the sliding internal fixation device.

Video 4 : Function of the knee operated on 04/12/2007, four months after surgery.

Video 5 : Walking on 05/14/2007, five months after surgery, undergoing adjuvant chemotherapy.

In this film we can observe the lameness and angular deviation of the knee. In the analysis of the control radiographs from 09/26/2007, figures 112 to 115, we can observe the angular deformity caused by the subluxation of the fibular head, laterally. We also observed that consolidation did not occur between the tibial epiphysis and the fibular epiphysis. Regeneration of the articular cartilage of the fibular epiphysis? Failed resection of this cartilage?
Figura 112: Radiografia pós operatório da perna direita, em 14/05/2007, frente, a seta vermelha assinala a sub-luxação da cabeça fibular. A seta amarela destaca a consolidação distal.
Figure 112: Post-operative radiograph of the right leg, on 05/14/2007, front, the red arrow indicates the subluxation of the fibular head. The yellow arrow highlights distal consolidation.
Figura 113: Radiografia pós operatório da perna direita, perfil.
Figure 113: Post-operative radiograph of the right leg, profile.
Figura 114: Radiografia pós operatório da perna direita, em 26/09/2007, frente, a seta vermelha assinala o aspecto da cabeça fibular. A seta amarela destaca o alargamento da diáfise da fíbula, devido ao espeçamento fibular.
Figure 114: Post-operative radiograph of the right leg, on 09/26/2007, front, the red arrow indicates the appearance of the fibular head. The yellow arrow highlights the widening of the fibular shaft, due to fibular spacing.
Figura 115: Radiografia pós operatório da perna direita, vista de perfil.
Figure 115: Post-operative radiograph of the right leg, profile view.

Video 6 : Patient undergoing chemotherapy, limping due to angular deviation, due to non-union of the proximal end of the fibula, on 09/26/2007, nine months after surgery.

On this occasion we decided to wait for the end of adjuvant chemotherapy to undergo reoperation to promote the consolidation of the fibular epiphysis with the tibial epiphysis and correct the deformity. In November 2007, he suffered a femur fracture, which was treated closedly with a foot pelvic cast for six weeks. There was good evolution. On December 17, 2007, we removed the plaster cast and released it for weight bearing, maintaining the plan to operate after the end of postoperative chemotherapy. In April we carried out imaging tests for control. Post-operative scintigraphy demonstrates the concentration of technesium in the proximal region of the transposed right fibula, indirectly indicating the maintenance of the growth potential of the fibular physis after transposition, as well as showing the capture of the callus from the fracture that occurred in the femur.
Figura 116: Cintilografia após a fratura do fêmur, em 07/04/2008, frente, em destaque a captação da cartilagem de crescimento da fíbula.
Figure 116: Scintigraphy after the femur fracture, on 04/07/2008, front, highlighting the capture of the fibula growth cartilage.
Figura 117: Cintilografia após a fratura do fêmur, em 07/04/2008, posterior.
Figure 117: Scintigraphy after femur fracture, on 04/07/2008, posterior.
Figura 118: Cintilografia após a fratura do fêmur, em 07/04/2008, destacando a captação do calo de fratura no fêmur.
Figure 118: Scintigraphy after the femur fracture, on 04/07/2008, highlighting the capture of the fracture callus in the femur.
Figura 119: Radiografia de 15/04/2008, após seis meses da fratura do fêmur, frente.
Figure 119: Radiograph from 04/15/2008, six months after the femur fracture, front.
Figura 120: Radiografia de 15/04/2008, após seis meses da fratura do fêmur, perfil, consolidada.
Figure 120: Radiograph of 04/15/2008, six months after the fracture of the femur, profile, consolidated.

Video 7 : Patient walking six months after the femoral fracture, waiting for the end of chemotherapy for reoperation.

Video 8 : Knee function, one and a half years after leg surgery and six months after the femur fracture.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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