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

This digital library houses the book on Oncology and Orthopedic Oncosurgery.

It includes academic lectures, presentations from national and international congresses, published papers, case discussions, performed surgical procedures, and proprietary techniques developed.

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Van-Ness gyroplasty

Van Ness gyroplasty

Figure 1: In the 1980s, the literature indicated that limbs affected by bone sarcomas should be amputated in children under 10 years of age. This was due both to the limitations of surgical resources at the time and to the high rates of poor results with conservative surgery, due to the marked discrepancy of the limbs with growth. Other medical dogmas also established ablation in cases of vascular involvement. Even at the 1988 Brazilian Orthopaedic Congress, held in Brasilia, this concept was a consensus. However, we challenged this premise, stating that vascular involvement could be circumvented with vascular grafts. We presented cases of oncological resection combined with reconstruction by vascular anastomosis, as in this case of an osteosarcoma involving the popliteal artery and vein, resected en bloc and reconstructed with a vascular graft and endoprosthesis.
Figure 2: And even back then, ablative surgery was indicated for: - Tumor lesions involving the vascular bundle. - Soft tissue involvement. - Tumors larger than 12 cm or with a fracture. - Neoplastic lesions in children under the age of 10. In this case, the alternative was amputation. However, in 1992, we met Professor Capanna at the SBOT Congress in São Paulo, who introduced us to the Van Nes technique, which is still indicated today. This technique consists of an intercalary resection, creating a deformity that is complex to accept in our Latin environment, requiring acceptance from the patient and family, as well as the difficulty in making the orthosis. We opted for the Van Nes gyroplasty, as it would not make it impossible to convert to amputation if there was no success.
Figure 3: Therefore, in this case of osteosarcoma in the distal third of the right thigh, compromising the femur, the muscles and the vascular bundle of the region, the indication for gyroplasty was carried out, performing an intercalary oncological resection, different from total amputation below the level of the proximal third of the femur. We opted to perform the Van Nes Gyroplasty, which consists of an intercalary resection of the two distal thirds of the thigh and the proximal segment of the leg, with preservation of the vascular bundle (artery and vein) and the sciatic nerve. It is an en bloc resection, including the skin, muscles, bones and subcutaneous tissue of the region, therefore a resection with an oncological margin, preserving the irrigation and innervation of the remaining extremity.
Figure 4: In the Van Nes Gyroplasty, we perform a 180° rotation of the lower extremity of the operated limb. We must calculate the necessary extension of the segment of the operated leg so that, at the end of the patient's skeletal maturity, the final level of the healthy knee joint is equal to that of the contralateral ankle. In this way, the level of the healthy knee joint will be symmetrical to the ankle of the operated side, which will function as a neo-joint, providing the patient with symmetry in the sitting position.
Figura 5
Figure 6: As recently as 1997, world literature indicated amputation as a treatment for tumors of the lower limb in children under 10 years of age, due to the future discrepancy of the lower limb. Note that the growth plate of the fibula is at the level of the ankle joint, while the growth plate of the tibia is at a higher level. We are therefore planning a transfer from the distal fibula to the tibia after resection of the tumor. It is worth noting that the fibular nutral artery and its growth plate enter the proximal third of the fibula. Therefore, our fibular osteotomy must be performed above this entrance. We also need to perform a lateral window for proximal splinting, followed by the creation of a cavity in the talus to receive the fibular epiphysis with its growth plate.
Figure 7: In this image, we can identify: - Surface of the talus. - Proximal segment of the tibia. - Interosseous membrane. - Entry point of the nutricial artery. - Fibular epiphysis. - Level of the fibula osteotomy proximally.
Figure 8: We are going to perform an arthrodesis between the talus and the remaining tibia, using the fibular epiphysis, which has already lost its epiphyseal cartilage, and transferring it through the interosseous membrane. In this way, we transfer the growth cartilage from the fibula to the tibia, performing an autotransplant of the growth plate through the interosseous membrane.
Figure 9: To finalize the arthrodesis, we made an oval cavity in the talus to adapt the fibular epiphysis, thus completing the procedure with the integration of the fibular epiphysis
Figure 10: We finalized this reconstruction by fixing it with a Steinmann pin through the calcaneus.
Figure 11: We accommodate the operated limb in the orthosis designed for this patient, transferring the growth plate from the fibula to the tibia, thus completing the procedure.
Figure 12: At 5 months, we observed bone neoformation and the transfer of the fibular plate to the tibia. Mapping shows that this segment is vascularized, confirming the success of the autotransplant.
Figure 13: At one year and five months, we can see good bone integration and thickening of the new tibia, with the fibular plate translated and viable
Figure 14: After 2 years, the patient shows good support and function, both in knee flexion and in monopodal loading.
Figure 15: In this second case of cartilage autotransplantation at the level of the ankle, we observed a lesion of bone rarefaction in the distal metaphysis of the tibia, with imprecise limits, surpassing the anterior and posterior cortices.
Figure 16: Scintigraphy shows increased uptake in the ankle, as evidenced by PET-CT. On the axial and sagittal T2 MRI slices with fat suppression, we see a large extra-cortical tumor with high signal intensity.
Figure 17: We made an inguino-podal plaster cast, which will serve as the basis for the custom-made orthosis.
Figure 18: The inguino-podal orthosis has already been made and is being tested for post-operative use.
Figure 19: We didn't use a tourniquet; we made an anterior incision in the leg and began to open the muscular fascia.
Figure 20: We opened the ankle joint and performed the osteotomy, allowing resection of the tibial segment with the neoplasm. Next, we prepared the lateral window in the tibia and carefully removed the epiphyseal cartilage from the fibula to insert it into the talus cavity
Figure 21: We expose the surface of the talus and remove an oval fragment of cartilage. With a curette, we remove the cancellous bone, creating a cavity that will receive the fibular epiphysis, which will be wedged. We insert a Kirchner wire through the fibula, which exits through the calcaneus, fixing the reconstruction for the arthrodesis.
Figure 22: The X-ray confirms the proper positioning of the Kirchner wire and shows the piece resected en bloc.
Figure 23: The control X-ray documents the reconstruction, confirming the completion of the surgery and the fitting of the orthosis.

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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