Proximal Tibia Resection
Carrie L. Heincelman
Megan E. Anderson
Operative Indications
Malignant tumors of the proximal femur—wide resection
Alternative Treatments
Rotationplasty
Through-knee or above-knee amputation
Co-surgeon
Plan for medial gastrocnemius flap ± split-thickness skin graft
Involvement of plastic surgeon
Equipment
Radiolucent table (use fluoroscopy for reconstruction)
Lead aprons not needed during resection usually
Tourniquet available (only needed to aid repair of unplanned vascular injury)
Doppler with sterile probe
Nerve stimulator available
Long ruler (300 mm)
Dissecting tools (eg, right angle clamp, Metzenbaum scissors)
Vascular clamps available
Vascular ties
Power saw
Osteotomes
Bone-holding clamp
Positioning
Supine
Pad prominences (sacrum, contralateral heel)
Long surgery and low body weight often contribute to high risk of decubitus ulcers
Small roll behind involved hip to position limb in slight external rotation, nearly neutral
Assess leg lengths in this position to restore this with reconstruction
Can place electrocardiogram (ECG) electrode on contralateral medial malleolus to aid in palpating under drapes
Gel bump to rest foot against with the knee in flexion
Drape entire extremity from lower abdomen and femoral triangle to toes (Figure 43.1)
 Figure 43-1 ▪ Operating room (OR) table setup. Note roll under operative hip and gel bump to support foot while the knee is in flexion. (Courtesy of Children’s Orthopaedic Surgery Foundation.) |
 Figure 43-2 ▪ Anteromedial incision with biopsy tract ellipsed out, which will stay with the resection specimen. (Courtesy of Children’s Orthopaedic Surgery Foundation.) |
Surgical Approach
Anteromedial
Extensile
Length of incision from just above patella to 2 to 5 cm distal to planned bone cut (depending on thickness of soft tissue envelope and size of soft tissue extent of tumor)
Surgeon on medial side of involved leg (reach across table) and assistant on same side as involved leg (Figure 43.2)
Technique in Steps
Initial Approach
Create full-thickness flaps (Figure 43.3)
Incise fascia over superficial posterior compartment
Keep intact entire length of wound for later repair (becomes part of retinaculum proximally)
Incise directly adjacent to medial border of tibia, but with enough tissue to cover soft tissue extent of tumor
Fascia on tibia will go with specimen; fascia preserved with soft tissue flap will aid in closure and decrease wound breakdown (Figure 43.4)
Bend knee with the posterior structures free (Figure 43.5)
Gastrocnemius falls away with gentle dissection
Figure 43-3 ▪ Raise full-thickness flaps. (Courtesy of Children’s Orthopaedic Surgery Foundation.)
Figure 43-4 ▪ Incise fascia along tibia. (Courtesy of Children’s Orthopaedic Surgery Foundation.)
Release medial hamstrings at pes anserinus (Figure 43.6)
Identify tibial neurovascular bundle (NVB) in popliteal fossa
With large proximal and posterior soft tissue mass, release medial gastrocnemius at its origin on femur to access popliteal fossa (Figure 43.7)
Neurovascular Dissection
Trace tibial NVB from popliteal fossa to proximal edge of soleus
Move to distal approach and release soleus off tibia with cuff of tissue over tumor distal to proximal
Release fascia of deep posterior compartment off medial border of tibia (Figure 43.8)
Figure 43-5 ▪ Note the flexed position of the knee to allow posterior structures to come off tension. Neurovascular bundle seen in popliteal fossa (green arrow). (Courtesy of Children’s Orthopaedic Surgery Foundation.)
Figure 43-6 ▪ The pes anserine tendons are transected. (Courtesy of Children’s Orthopaedic Surgery Foundation.)
Release flexor digitorum longus off medial posterior tibia leaving cuff of tissue on tumor
Identify posterior tibial NVB in deep posterior compartment and trace from distal to proximal, tying off branches to tumor (Figure 43.9)
With NVB protected above and below soleus arcade, release soleus origin off tibia
Dissection has to be precise due to soleus origin, trifurcation of vessels and neighboring fibula so have proximal and distal control as soleus is released
May need to dissect into soleus muscle instead of releasing tendon with a large soft tissue massRelated posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
