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%.