HIROATSU NAKASHIMA, MASAHIRO YOSHIDA & KENTARO MIYAMOTO. Department of Orthopedic Surgery, Aichi Hospital, Aichi Cancer Center, Okazaki, Japan

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1 Upsl Journl of Medicl Sciences. 2012; 117: CASE REPORT Antomicl reconstruction of the ptellr tendon using the fsci lt ttched to the ilic one following resection for soft tissue srcom: A cse report HIROATSU NAKASHIMA, MASAHIRO YOSHIDA & KENTARO MIYAMOTO Deprtment of Orthopedic Surgery, Aichi Hospitl, Aichi Cncer Center, Okzki, Jpn Astrct A new reconstruction of the ptellr tendon ws performed in 43-yer-old ptient who lost tendon nd tiil tuerosity fter wide tumor resection for low-grde myofirolstic srcom of the prptellr tendon. In this technique, the ptellr tendon ws ntomiclly reconstructed using fsci lt ttched to the ilic one. The ilic one ws fixed to the tiil ony trough with sorle screws, nd the fsci lt ws fshioned into three rnches: the centrl rnch ws folded through the tunnel in the ptell, nd the medil nd lterl rnches were tgged to the medil nd lterl retinculum, respectively, round the ptell. The skin defect ws covered y the ilterl hed of the gstrocnemius flp nd split-thickness skin grft. At the 3-yer follow-up, the ctive rnge of motion of the knee joint ws 0 to 110 degrees. The functionl result ccording to the Musculoskeletl Tumor Society scoring system ws 97%. Rdiogrphs showed tht the grfted one ws united well to the tiil one, nd the grfted fsci ws confirmed s drk nd on MRI. There ws no evidence of disese nd no complint of the donor site. This procedure llows for the reconstruction of the ptellr tendon in the originl loction. To our knowledge, this reconstructive procedure of the ptellr tendon using the fsci lt ttched to the ilic one hs never een reported in English literture. Key words: Fsci lt, ptellr tendon, reconstruction, soft tissue srcom Introduction Low-grde myofirolstic srcom represents distinct typicl myofirolstic tumor, often with firomtosis-like fetures. It occurs predominntly in dult ptients with slight mle dominnce. The tumor shows wide ntomic distriution; however, the extremities nd the hed nd neck region pper to e preferred loctions. Cliniclly, locl recurrences re common, wheres metstses only occur rrely (1). Therefore, wide surgicl resection of the tumor is importnt. We report cse of low-grde myofirolstic srcom, involving the region djcent to the tiil tuerosity nd the ptellr tendon, in 43-yer-old womn. The defect of the ptellr tendon following lim-spring wide tumor resection ws reconstructed y the fsci lt ttched to the ilic one nd covered with the gstrocnemius flp. To our knowledge, this type of reconstructive procedure hs never een reported in English literture. Cse report A 43-yer-old womn visited generl clinic with pinless tumor of the right nterior knee region nd underwent excision of the tumor under locl nesthesi. The pthologicl dignosis ws spindle cell srcom, nd the lesion recurred loclly. She ws referred to our hospitl 2 months fter the initil excision. Physicl exmintion of the right nterior knee region reveled the trnsverse excision scr nd tumor t the medil side of the tiil tuerosity. The tumor Correspondence: Hirotsu Nkshim, MD, Deprtment of Orthopedic Surgery, Aichi Hospitl, Aichi Cncer Center, 18 Kuriydo, Kke-mchi, Okzki, Aichi Prefecture, , Jpn. Fx: E-mil: hnksim@cc-ichi.com (Received 17 April 2012; ccepted 24 April 2012) ISSN print/issn online Ó 2012 Inform Helthcre DOI: /

2 Antomicl ptellr tendon reconstruction 461 Figure 1. Mgnetic resonnce imges of the tumor t the initil presenttion. The tumor showed low signl intensity on T1-weighted imges () nd high signl intensity on ft-suppressed T2-weighted imges (). The tumor ws locted closely to the ptellr tendon, nd prt of the tumor crept eneth the tendon. A high signl intensity re, suggesting edem, ws seen round the tumor. ws elstic nd soft, nd movle, nd its longitudinl dimeter ws 3 cm. Diffuse swelling ws seen round the tumor. The rnge of motion of the knee joint ws norml. Plin rdiogrphs showed no normlity. Mgnetic resonnce imging (MRI) showed wellmrgined mss djcent to the ptellr tendon nd tht prt of the tumor crept under the ptellr tendon. The tumor showed low signl intensity on T1-weighted imges nd high signl intensity on T2-weighted imges. Ft suppression T2-weighted imges showed high signl intensity re round the tumor, suggesting edem (Figure 1). The swelling of the surrounding tissue ws severe. Thus, if dditionl wide resection with the sfety surgicl mrgin including this edem re were to e estlished, the extent of skin nd sucutneous tissue excision ws expected to e considerle. Therefore, preopertive rdition (totl dose 25 Gy) ws performed in order to reduce the surgicl mrgin. MRI fter preopertive rdiotherpy showed the reduction of the tumor size (reduction rte 34%), nd the extent of high signl intensity round the tumor ws reduced on ft suppression T2-weighted imges (Figure 2). We estlished 3 cm skin mrgin from the edem re, nd performed wide resection of the tissues surrounding the tumor, including lmost the full length of the ptellr tendon (the ptellr tendon ws resected trnsversely 1 cm from the inferior pole of the ptell), the infrptellr ft pd, nd the tiil tuerosity. Ptellr tendon reconstruction A4 10 cm portion of the fsci lt ttched to ilic one ws hrvested. The surgicl technique dopted ws similr to tht descried in Cmpell s opertive orthopedics (2). The one trough in the tii ws Figure 2. MRI fter preopertive rdition therpy. The size of the tumor ws reduced, nd the high signl intensity re ws decresed.

3 462 H. Nkshim et l. Slit in qudriceps tendon Ptellr tunnel Medil lim Lterl lim Centrl rnch Fix the ilic one y sorle screws Figure 3. Reconstruction of the ptellr tendon using the fsci lt ttched to the ilic one: intropertive photo () nd schemtic drwing (). The centrl rnch of the grft ws pssed through n 8 9 mm longitudinl tunnel nd then through slit in the qudriceps tendon. mde with n oscillting sw out 4 cm distl to the joint line. Contouring of the corticocncellous ilic one ws performed to fit the tiil ony trough, nd the ony portion ws fixed with two 4.5 mm sorle corticl screws. The fsci lt portion ws fshioned into three rnches, with the centrl third consisting of hlf of the width. This centrl rnch ws 8 9 mm in dimeter. A Kirschner wire ws pssed through the centrl prt of the ptell to mke tunnel. An 8 9 mm remer ws pssed over the Kirschner wire. A whipstitch ws mde with nonsorle suture in the centrl rnch, nd this centrl rnch ws pssed through the tunnel, exiting through slit in the qudriceps tendon. Multiple interrupted non-sorle sutures were plced through the grft in the soft tissue of the inferior pole of ptell nd t the edges of the qudriceps tendon (Figure 3). The pproprite grft length nd tension were determined s follows. The position of the inferior pole of the ptell ws situted t the upper portion of the intercondylr notch t 45 degrees knee flexion. A lterl view rdiogrph of the knee joint ws otined to confirm the height of the ptell compred with the opposite side. Ptellr trcking ws Figure 4. Clinicl photo tken 3 yers fter the opertion showed ctive knee flexion of 110 degrees (). The ptient is le to rise her leg with n extension lg of 5 degrees ().

4 Antomicl ptellr tendon reconstruction 463 Figure 5. Lterl-view rdiogrph () nd MRI () tken 3 yers fter the opertion. Bone union is otined well nd the Insll Slvti index is 1.6 (the opposite knee is 1.1). Therefore, the ptell lt is seen. The grft is shown s drk nd on the T2-weighted imge (). checked crefully. The medil nd lterl rnches of the grft to the medil nd lterl retinculum were tgged, respectively, using non-sorle sutures. The skin defect ws covered y the ilterl hed of the gstrocnemius flp nd split-thickness skin grft. The pthologicl dignosis of low-grde myofirolstic srcom ws mde. Postopertive rehilittion Postopertive swelling in the lower leg ws severe, nd peronel nerve plsy developed, ut improved 3 months fter opertion. The ptient ws initilly treted with splint for 3 weeks with the knee in full extension. Continuous pssive motion ws initited to move the knee etween 0 nd 30 degrees, nd this rnge ws grdully incresed. At the sme time, isometric qudriceps strengthening exercise ws egun. After 4 weeks postopertively, weight-ering to tolernce with crutches ws llowed until sufficient motion nd strength llowed for unssisted multion. Physicl exmintion t 3 yers postopertively showed ctive knee motion of 0 to 110 degrees. She ws le to rise her leg with n extension lg of 5 degrees (Figure 4). The functionl result ccording to the Musculoskeletl Tumor Society (MSTS) scoring system (3) ws 97%; pin, function, emotionl cceptnce, supports, nd wlking were 5 points, respectively, nd git ws 4 points. Rdiogrphs showed tht the grfted one ws united well to the tiil one, nd the grfted fsci ws confirmed s drk nd on T1- nd T2-weighted imges (Figure 5). There ws no evidence of systemic or locl recurrence nd the donor site ws cliniclly unffected. Discussion There hve een very few reports on reconstruction of the ptellr tendon fter wide tumor resection such s in this cse (4,5). Fukui et l. (4) reported cse with soft tissue srcom close to the ptellr tendon. The ptellr tendon nd tiil tuerosity were resected due to wide resection of the tumor. The ptellr tendon ws reconstructed with grft composed of the ipsilterl hmstring tendon nd iliotiil trct. Both ends of the grft were fixed in the one tunnels in the ptell nd tii y screw fixtion. Twenty months postopertively, full rnge of the knee joint ws chieved without extension lg. Mchens et l. (5) reported cse with preptellr myxofirosrcom. Lim-sving rdicl tumor resection ws chieved y resection of the cudl qudriceps muscle, ptell, collterl ligments, nd ptellr tendon. The lrge defect ws covered y free myocutneous ltissimus dorsi flp. The ptellr tendon ws replced y insertion of the flp, nd the musculr flp origin ws connected to the remining qudriceps muscle. The ptient ws le to extend his knee joint ctively without ny externl support 3 months fter

5 464 H. Nkshim et l. opertion, ut clinicl photogrphs, otined 9 months lter,showed therngeofhiskneetoeout70degrees flexion nd with n extension lg of out 10 degrees. Peyser nd Mkley (6) reported new reconstruction of the ptellr tendon in 10-yer-old oy with synovil srcom in the preptellr tendon region. The inferior pole of the ptell, ptellr tendon, nd tiil tuerosity were resected completely long with the ptellr tendon. The iceps tendon ttched to the fiulr hed ws hrvested, nd the fiulr hed ws fixed to the trough mde from resection of the tiil tuerosity using screw. The iceps tendon ws sutured proximlly to the qudriceps tendon nd reinforced with the semitendinosus tendon nd reversed qudriceps tendon. In this technique the reconstructed ptellr tendon ws locted in the exct ntomicl loction of the originl tendon, similr to our procedure. Fukui et l. (4) reported tht success in reconstruction of the ptellr tendon ws dependent on the strength nd nchoring of thegrft,ndthe ntomicgrft loction.noyes etl.(7) reported the iomechnicl nlysis of vriety of grft tendons used in ligment reconstruction. The ptellr tendon one grft ws the strongest, nd its centrl or medil portions of one-third width hd greter strength (159% to 168%) compred with the nterior crucite ligments. The semitendinosus nd grcilis tendons were stronger (70% nd 49%, respectively) compred with the nterior crucite ligments, nd the iliotiil trct nd fsci lt hd strength of 44% nd 36%, respectively. However, the fsci lt 45 mm in width hd strength of 104% of the nterior crucite ligment, nd wider grfts from the fsci lt could increse the strength. In our cse, the hrvested fsci lt ttched to the ilic one ws 4 mm in width, ut the fsci ws folded ck, so the grft fsci ppered to e suitlefor the strength required from the iomechnicl nlysis of Noyes et l (7). Regrding nchoring of the grft, it is importnt to otin firm grft-to-one heling in reconstruction of the ptellr tendon, nd it is importnt to locte the reconstructed grft in the exct ntomicl loction of the originl tendon to regin the norml iomechnics of the ptellofemorl joint nd to decrese the risk of susequent degenertive chnges in the ptell (4,6). We reconstructed the ptellr tendon using the fsci lt ttched to the ilic one for ntomicl reconstruction. A similr technique using the tendo clcneus llogrft ppers in Cmpell s opertive orthopedics (2). At the 3-yer follow-up, our ptient ws le to rise her leg with n extension lg of 5 degrees nd otined good results with 97% of the MSTS score. This study is cse report, nd lrger series of ptients treted using this technique would e needed to evlute the utility of this method. However, from this experience, the present procedure my e recommended for the tretment of neglected ruptures of the ptellr tendon or trumtic defect of the tendon. Declrtion of interest: The uthors report no conflicts of interest. The uthors lone re responsile for the content nd writing of the pper. References 1. Mentzel T, Fletcher JA. Low grde myofirolstic srcom. In Fletcher CDM, Unni KK, Mertens F, editors. Pthology nd genetics of tumours of soft tissue nd one. World Helth Orgniztion clssifiction of tumours. Lyon, Frnce: IARC Press; p Phillips BB. Trumtic disorders. Cmpell s opertive orthopedics. 8th ed. St Louis: Mosy; p Enneking WF, Dunhm W, Gehrdt MC, Mlwr M, Pritchrd DJ. A system for the functionl evlution of reconstructive procedures fter surgicl tretment of tumors of musculoskeletl system. Clin Orthop. 1993;286: Fukui N, Cho N, Tshiro T, Nkmur K. Antomicl reconstruction of the ptellr tendon: new technique with hmstring tendons nd iliotiil trct. J Orthop Trum. 1999; 13: Mchens HG, Siemers F, Kun M, Krpohl B, Reichert B, Russlies M, et l. Ptellr tendon reconstruction using free ltissimus dorsi flp following resection of ptellr myxofirosrcom: cse report. J Reconstr Microsurg. 2005;21: Peyser AB, Mkley JT. Ptellr tendon reconstruction ugmented y free utogrft of the iceps tendon ttched to the fiulr hed. Ortopedics. 1996;19: Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechnicl nlysis of humn ligment grfts used in knee ligment repirs nd reconstruction. J Bone Joint Surg Am. 1984;66: