Discussion
Some limb salvage patients with bone sarcomas will undergo amputations
secondary to tumor recurrence, mechanical failure, infections, and
fractures. Those amputations are frequently proximal transfemoral or hip
disarticulations owing to severe distal femoral bone loss. (6).
Patients with higher amputation levels invariably have lower functional
scores. Previous studies have demonstrated that a proximal level of
amputation is associated with less energy-efficient walking and slower
walking speed. In above-knee amputations, the stump length is shown to
have a significant impact on the physiological cost index (PCI),
increasing metabolic demands by>50% compared with healthy
individuals (2,7). Thus, maximizing the stump length provides less
impact on the gait balance, with better prosthetic fitting.
Tibial turn-up plasty is a reconstructive procedure used to increase the
length of above-knee amputations. The main objective of the intervention
is to achieve a longer stump that is functionally superior to proximal
transfemoral amputation or hip disarticulation (8).
This procedure is a reasonable alternative in circumstances where
reconstruction is not feasible in the context of a tumor recurrence,
untreatable osteomyelitis, and severe posttraumatic femoral bone loss
(9). A tibial turn-up is also valid in extremely young patients with
bone sarcomas, where the predicted limb-length discrepancy is
unacceptable. This procedure substantially decreases the need for
revision surgeries in those scenarios (1,10).
Historically, the first report of tibial turn-up was described by
Sauerbruch in 1922 (11). The original German manuscript was ”The
extirpation of the Femur with the Plastic Overturning of the Lower Leg.”
Sauerbruch described the case of a 13-year-old female with chronic
posttraumatic osteomyelitis of the femur, treated with surgical
debridements without success, and a second case of pathological femur
fracture in a male in his forties. Since the initial report, the main
objective was to bring an advantage for fitting the prosthesis.
Subsequently, published techniques are modifications to the original
article of Sauerbruch (11), all to optimize the femoral stump length.
Borggreve (12) originally described rotantioplasty in 1930 in treating
severe limb deformity secondary to tuberculosis. Van Ness published the
technique in English literature for the first time in 1948 (13),
describing partial and total turn-up plasty. The same author described
the ”turn-up plasty of the leg” in 1964, reporting the use of fibular
strut as an endomedullary autograft for the first time. In 1956,
Nicholson and Wider (14) described a tibial turn-up plasty combined with
a hip prosthesis, where the femur was excised entirely, and the femoral
stem of the prosthesis was fit in the distal part of the tibia after the
latter was rotated proximally.
Peterson et al. (15) described a novel technique of rotating the tibia
and hindfoot to the hip joint entirely and performing a calcaneopelvic
fusion to recreate a new hip through the tibiotalar joint.
In this article, we describe the case of a 46-year-old male with chronic
treatment-resistant osteomyelitis of his distal left femur and a prior
history of distal femoral osteosarcoma. The above-knee amputation would
result in an extremely short femoral stump, and we decided to optimize
the length with the tibial turn-up plasty. We followed the same
dissection principles as the original description of Sauerbruch
Of the few published articles on tibial turn-up plasty of which we are
aware, only 2 two reports utilized the fibular strut autograft in an
intramedullary manner to improve structural support and facilitate bone
consolidation. Sojka et al. (4) described a similar technique using an
intercalary fibular autograft. They reported a 20-year-old man with
chronic osteomyelitis with a previous history of metastatic
rhabdomyosarcoma of the distal right femur. Instead of rotating the
tibia, they fused the distal femur to the proximal tibial, and the
fibular strut was used to stabilize the junction. Complementary fixation
was performed with a locking compression plate in the femorotibial
construct.
Kasis et al. (9) reported the case of a 26-year-old male with severe
distal femoral bone loss secondary to a road traffic accident with
secondary osteomyelitis. They performed the tibial turn-up with the same
surgical principles. However, they used external fixation for the
reconstruction, achieving complete consolidation.
Douglas et al. (16) reported one of the most cited series to date
regarding functional outcomes. Seven patients with a prior history of
distal femur malignancy were included; five patients underwent the
procedure because of a failed limb salvage, and two as a primary
reconstructive procedure. At the final follow-up, all patients could
ambulate with above-knee prostheses. Only one patient, with soft tissue
leiomyosarcoma, had tumor recurrence in the pelvis, requiring a
hemipelvectomy one year after the procedure.
Ramsey et al. (3) recently published the largest series regarding
functional and surgical outcomes in tibial turn-up plasty. They included
ten patients between 2003 and 2021 by a single orthopedic oncology
division. Ten of the 11 patients were ambulatory at the final follow-up,
80% using a simple assistive device and two ambulating unassisted. This
finding is concordant with our patient, who completed the prosthetic
fitting 11 months after the surgery and ambulated with the transfemoral
prosthesis using a single cane at the final follow-up.
Ramsey series (3) revealed that all patients had chronic infections
after arthroplasty or oncologic reconstructions, with a median number of
13 surgeries before turn-up plasty and six of eleven patients underwent
at least one reoperation after turn-up plasty, mainly because of wound
infection. Our patient exhibited a similar clinical course, requiring
more than 20 surgeries before deciding on an ablative procedure, and
after turn-up plasty, he underwent irrigation and debridement because of
infection.
Our patient showed substantial improvements, especially in function,
gait pattern, and pain control, and achieved a complete prosthesis fit.
At two years of follow-up, MSTS was 18/30, compared with 7/30 before the
intervention. Tate et al. (17) reported the case of a 4-year-old boy
with distal femoral osteosarcoma who underwent the procedure. They
described an MSTS of 25/30 after two years postoperatively, a higher
score than our case, probably because the younger age has better
possibilities of social reintegration and participation, and the
preservation of proximal tibial physis allowed continuous growing of the
stump. However, our patient’s proportional change of MSTS was
meaningful, with an improvement of 36%.