Anatomical Reconstruction of the Knee Extensor Apparatus for Prepatellar Myxofibrosarcoma

Abstract

A novel reconstruction of the knee extensor apparatus was attempted in a 69-year-old patient with prepatellar myxoid fibrosarcoma. The skin (35×25 cm), subcutaneous tumor, quadriceps tendon, patella, anterior capsule, and patella tendon were widely resected en-bloc. Following wide resection, the excised quadriceps tendon, patella, and patella tendon were anatomically reimplanted into the original site after being devitalized in liquid nitrogen. These complexes were covered by a free vascularized latissimus dorsi myocutaneous flap. At 18-month follow-up, the strength of active knee extension was 4+ of 5 in the muscle manual test. The active range of motion was 110° in flexion and -10° in extension. The tumor showed no evidence of disease. The patella and femur joint showed no osteoarthritis on plain radiographs. This procedure is the only way to achieve anatomical reconstruction. Reattachment of patella tendon to the tibial tuberosity was possible. The use of liquid nitrogen to devitalize is straightforward and the operation time can be shortened. To our knowledge, this type of reconstructive procedure has never been reported in the English literature.

Functional reconstruction of the knee extension mechanism following wide resection for a prepatellar soft-tissue sarcoma: A case report

“…However, Muramatsu's procedure (6) used a simple method for tissue freezing (outside of the body without continuity), which has the advantage of preventing frostbite. Although Muramatsu et al (6) did not report their patient's ISOLS score, the final limb function of the patient in the present study is thought to be superior, based on the wider active ROM and stronger MMT scores.…”

“…4 and Table I. An advantage of the current procedure when compared with Muramatsu's procedure (6), is the continued blood supply to the frozen tissue through the preserved rectus femoris muscle, which may lead to a shorter period of bone union and fewer postoperative complications (9). Another advantage is the firm fixation of the patellar tendon by bone-to-bone fixation with screws.…”

“…A similar surgical procedure was previously described by Muramatsu et al (6). The quadriceps tendon, patella, and patella tendon were resected with a prepatellar soft tissue sarcoma (myxofibrosarcoma).…”

“…For the coverage of the liquid nitrogen-treated patella in the present case, a medial gastrocnemius flap was used, whereas Muramatsu et al (6) utilized the LD free flap. Although the use of an LD free flap requires a more complicated method than a gastrocnemius flap, it's use may be considered depending on the location of the tumor and the size of soft tissue defect.…”

“…Although some surgical options including latissimus dorsi (LD) free flap (2), allografting (3), free grafting of the fascia lata with the iliac bone (4) and a pedicle medial gastrocnemius flap (5), have been reported to date, to the best of our knowledge, only one case report in which the knee extensor mechanism was biologically reconstructed with a free frozen autograft has been published (6).…”