Extensor Function After Medial Gastrocnemius Flap Reconstruction of the Proximal Tibia

Abstract

Background Reconstruction of the extensor mechanism after resection of the proximal tibia is challenging, and several methods are available. A medial gastrocnemius flap commonly is used, although it may be associated with an extensor lag. This problem also is encountered, although perhaps to a lesser extent, with other techniques for reconstruction of the extensor apparatus. It is not known how such lag develops with time and how it correlates with functional outcome. Questions/purposes We therefore (1) assessed patellar height with time, (2) correlated patellar height with function using the Musculoskeletal Tumor Society (MSTS) score, and (3) correlated patellar height with range of motion (ROM) after medial gastrocnemius flap reconstruction. Methods Sixteen patients underwent tumor endoprosthesis implantation and extensor apparatus reconstruction between 1997 and 2009 using a medial gastrocnemius flap after sarcoma resection of the proximal tibia. These patients represented 100% of the population for whom we performed extensor mechanism reconstructions during that time. The minimum followup was 2 years (mean, 5 years; range, 2-11 years). Fourteen patients were alive at the time of this study. We used the Blackburne-Peel Index to follow patellar height radiographically with time. Functional outcomes were assessed retrospectively using the MSTS, and ROM was evaluated through active extensor lag and flexion. Results Eleven patients had patella alta develop, whereby the maximal patellar height was reached after a mean of 2 years and then stabilized. More normal patellar height was associated with better functional scores, a smaller extensor lag, but less flexion; the mean extensor lag (and flexion) of patients with patella alta was 17°(and 94°) compared with only 4°(and 77°) without. Conclusions In our patients patella alta evolved during the first 2 postoperative years. Patella alta is associated with extensor lag, greater flexion, and worse MSTS scores.

Proximal Tibia Reconstruction After Bone Tumor Resection: Are Survivorship and Outcomes of Endoprosthetic Replacement and Osteoarticular Allograft Similar?

“…The majority of osteoarticular allograft failures occurred within 24 months with infection being the most prevalent as had been reported previously [15,16]. It has been reported that the introduction of gastrocnemius flaps for soft tissue coverage after a proximal tibia resection has led to a decline in postoperative infection rates [13,20]. Three patients with limb salvage reconstruction failure could not be classified by Henderson classification: one patient (endoprosthetic group) with a postoperative lower limb ischemia that resulted in an above-knee amputation and two patients (osteoarticular allograft group) who developed severe osteoarthritis resulting in revision surgery to allograftcomposite prostheses.…”

“…Reconstruction of the extensor mechanism after proximal tibia tumor resection is a major concern and its success has shown some relationship with functional outcomes [2,3,5]. Reconstruction with allogeneic tissue from the proximal tibia allograft sutured to the recipient's remnant patellar tendon can restore and stabilize active knee extension, whereas the suture of the medial gastrocnemius flap to the extensor mechanism after endoprosthetic reconstruction has shown acceptable results [12][13][14]. We found that patients treated with allograft had better active extension with less extensor lag than attaching the patella ligament directly to the transposed gastrocnemius flap.…”

Use of local muscle flaps to cover leg bone exposures

“…The gastrocnemius and soleus muscles, being vascularized predominantly in their proximal regions, allow the rotation about the axis of the pedicle (good arc of rotation), without compromising vitality. They thus offer a good option for bone and soft tissue coverage of the Table 1 Table 1 Table 1 Table 1 Table 1 proximal and middle thirds of the leg, being the most used, usually individually [8][9][10][11][12][13][14][15][16] . In some situations, one may employ the soleus associated with one of the belies of the gastrocnemius 17 .…”

Knieendoprothetik nach Trauma

“…1). Weiterhin gilt grundsätzlich, dass die zuletzt verwendete Inzision oder die lateralste die geringste Nekroserate besitzt und deshalb zu bevorzugen ist [7]. Sicherlich spielen auch das Alter der Narbe mit entsprechend besserer Reperfusion und der Abstand zwischen den Inzisionen hinsichtlich des Nekroserisikos eine Rolle.…”