Proximal Tibia Resection



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




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)













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













        • 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

Jun 9, 2022 | Posted by in Reconstructive surgery | Comments Off on Proximal Tibia Resection
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