• Rua General Jardim, 846 cj 41 Higienópolis, São Paulo - SP

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Tibial Prosthesis in Ewing’s Sarcoma

Endoprosthesis Implantation Technique for Replacing the Proximal Third of the Tibia

Figure 2: With the patient in the horizontal dorsal decubitus position, we made an incision that passed through the crest of the tibia and deviated to the medial side, skirting an island intended for resection of the biopsy path, then followed medially through the septum of the vastus medialis muscle towards Hunter's canal.
Figure 3: No tourniquet was used and, as can be seen, there is no visible bleeding in the operating bed. The surgery was carried out carefully, with cauterization from the small subcutaneous vessels. We started with a superficial incision in the skin, proceeding with the electric scalpel through the fatty tissue, using cautery and Blend Spray 20/20 coagulation.
Figure 4: We proceeded with the dissection using the electric scalpel, advancing through the intermuscular septa. We used the cautery as if it were a rugina to detach the periosteum.
Figure 5: We carefully exposed the genicular vessels to perform the ligation of the larger caliber vessels, promoting a delicate division of the tissues in order to avoid any blood loss, especially in a patient already weakened by chemotherapy.
Figure 6: We measure the segments of the femur and tibia that we need to resect and mark the osteotomy points with an electric scalpel. We then defined the alignment of the tibial crest with the femur, creating an objective parameter for the proper positioning of the prosthesis segments, guaranteeing the preservation of the correct rotation of the limb.
Figure 7: Next, we first perform the osteotomy of the femur, using an electric saw or, as in this example, a Gigli saw.
Figure 8: We carefully check the total size of the planned endoprosthesis.
Figure 9: We then completed the procedure with an osteotomy of the tibia, resecting the entire previously planned segment en bloc.

Video 1: We complete the regularization of the osteotomies in order to obtain flat and perpendicular surfaces to the cuts, guaranteeing the perfect adaptation of the prosthesis components.

Figure 10: We received the components assembled in this way: first, we had to remove the rotating polyethylene component and disassemble it.

Video 2: After removing the interference bolt and the cross pin, we put the two polyethylene bushes out of the chamfer.

Video 3: After fitting the second bushing, we continue assembling the rotational component with the femur segment.

Video 4: We place the rotational pin with the chamfer facing forward to make it easier to place the locking pin.

Video 5: By slowly turning the rotational pin with a wrench, we find the orientation of the thread to secure it with the locking screw.

Video 6: With the slot aligned, we fix the locking screw in the slot of the rotational pin.

Video 7: We loosen the fixing screws on the femoral stem to fit it correctly.

Video 8: We compact the stem socket, which is slightly conical, with two to three strokes.

Video 9: After impaction, we tighten the screws of the femoral component, firmly locking the proximal stem.

Video 10: We now loosen the locking screws of the tibial component and the extension segment, which in this case is 3.0 cm, in order to assemble the planned component. We previously positioned the face that simulates the tibial crest line, in order to improve the orientation of the correct rotation during cementation.

Video 11: We also compacted the tibial stem and tightened all the locking screws on both the tibial component and the extension segment, firmly securing the entire assembly.

Figure 11: We have completed the assembly of our endoprosthesis, as planned.

Video 12: We start cementing the tibia first, leaving a tube of saline to rinse out the entire canal and pressing the cement in well to ensure that the prosthesis is well fixed. It is important to press the cement well, especially when we don’t have a pressurizer, which allows the cement to be filled from the bottom to the surface. The tibial prosthesis is inserted, orienting the anterior surface of the prosthesis with the alignment of the second metatarsal.

Figure 12: We remove the excess cement and maintain pressure and alignment throughout the drying process, which can vary depending on the supplier and the temperature of the operating room.

Video 13: To cement the femoral component, we clamp the diaphysis with Spanish forceps and place an IV bag to drain the medullary canal, removing air and any remaining blood. We continue to pay attention to filling the canal, remove the saline bottle and complete the manual pressurization of the cement, ensuring that the femoral canal is completely filled. We then inserted the femoral component stem, guiding the team to ensure correct alignment. Manual placement of the cement can accelerate its hardening, and it is sometimes necessary to apply force to complete the placement of the femoral component. Remove excess cement and check alignment. We must maintain compression and the limb aligned during the remaining minutes of cement expansion until it dries completely, ensuring that rotational alignment is maintained.

Video 14: With the limb at 90 degrees, we perform a slight traction and fit the components, completing the reduction of the new knee. Keeping the patella in the femoral groove, we tested the flexion-extension and coverage of the prosthesis, also assessing the closure of the surgical wound.

Figura 13: Após a cuidadosa revisão da hemostasia, passamos à inserção do ligamento patelar na prótese tibial, testando a flexo-extensão.
Figura 14: Após a colocação do dreno, completamos o fechamento do plano muscular.
Figure 14: We proceeded to close the subcutaneous tissue and the skin.
Figure 15: The immediate postoperative X-ray shows the good alignment of the parts and the femoral cement containment plug.
Figure 16: Frontal and lateral radiographs, with image inversion, show the good positioning of the components.
Figure 17: In detail, we can see the cement containment plug in an excellent position.
Figure 18: Frontal and lateral radiographs, with good cementation, and panoramic images of the entire lower limb show adequate reconstruction with the replacement prosthesis for the proximal third of the tibia.
Figure 19: Patient operated on in 2017, currently 7 years and 6 months post-operatively, healed and with good functionality.
Figure 20: Flexion with symmetrical loading, with the operated limb on the left bearing the weight.
Figure 21: Right limb, operated on, over the left, with good function and symmetry.

Video 15: Patient operated on more than 7 years ago, cured, with normal ambulation, no claudication, good gait and excellent function.

Case Author

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

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

Office :  Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638  Cell:+55  11 99863-5577   Email:  drpprb@gmail.com

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