Twenty cases of malignant sarcomas of the foot and ankle included: four osteosarcomas, three Ewing’s sarcomas, three chondrosarcomas, three fibrosarcomas, five synovial cell sarcomas, one clear cell sarcoma and one malignant schwannoma. Five-year survival was: three of the nine who had B-K amputation, five of the nine who had more distal amputation or local resection, for a total of eight of eighteen. More distal amputation than B-K or local resection was offered if plantar sensation and stability of the foot could be retained, and was accepted by half of the patients. There were no local recurrences of eighteen operated. Twenty cases of malignant sarcomas of the foot and ankle seen over a ten-year period from 1985 to 1995 were reviewed retrospectively. Eleven tumors arose from bone and nine from soft tissue. The bone tumors were: four osteosarcomas, three Ewing’s sarcomas, three chondrosarcomas, and one fibrosarcoma. The soft tissue sarcomas were: five synovial cell sarcomas, two fibrosarcomas, one clear cell sarcoma and one malignant schwannoma. The average age for all patients was twenty-four years. Two patients presented with chest metastases, both had palliative radiation and one had palliative B-K amputation. The surgical treatment given for the eighteen non-metastatic cases was: B-K amputation nine, Symes, Chopart, or ray amputation six, and wide excision of the tumor three patients. Five-year survival was eight of eighteen: three of the nine who had B-K amputation, four of the six who had more distal amputation, and one of the three who had local resection. There were no local recurrences, all deaths were from distant metastases. Although B-K amputation is often recommended, in our series more distal amputation or local resection was offered for the non-metastatic patient if plantar sensation and stability of the foot could be retained. This gave good function in nine of eighteen patients, with no local recurrences. A long duration of symptoms before presentation or referral influenced the outcome of the disease. In selected patients, amputation more distal than B-K level or wide local resection can give good function without compromising the prognosis.
The proximal radio-ulnar joint (PRUJ) is expendable, as radial head excision for fracture is known to leave an acceptable deficit. This paper discusses a technique for turning the PRUJ The prerequisite for the procedure is an intact PRUJ. After olecranon osteotomy (or after osteotomy at the same level if there is ankylosis between humerus and ulna), another more distal osteotomy of both the radius and ulna is done, just proximal to the biceps insertion into the radius, using a posterior approach. This creates a segment of proximal radius and ulna, including the PRUJ. This segment is then rotated 90° and fixed to the distal end of the humeral shaft and proximal end of the ulnar shaft. Interposed between humerus and ulna, the PRUJ functions as a vascularised, innervated synovial elbow joint. The range of motion of this new ‘elbow’ is potentially the same as pronation-supination, i.e., 160°. Three young adults have had the procedure. One young woman had undergone resection of the distal humerus for chondrosarcoma. Later a vascularised fibular graft was used to replace the shaft, but she had no elbow joint and had to use a sling because of instability. The second patient had nonunion of the distal humerus and an ankylosed elbow, with motion only through the nonunion. The third patient had a 10-year old arthrodesis of the elbow following a childhood infection. The PRUJ was intact in all three. Postoperative elbow movement ranged from 70° to 120°. There was some mild lateral instability. The lost function was that of a radial head resection, so adequate pronation and supination were retained. Because it uses a vascularised, innervated synovial joint, PRUJ-plasty is potentially good for life, making it superior to any synthetic prosthesis.
When amputation just below the knee becomes necessary after extensive loss of bone from the tibia and of anterior soft tissue in the treatment of tumours, fractures or infection, the remaining proximal tibia may be too short for a below-knee prosthesis, although the knee may be normal. We have included the distal tibia or foot in a long posterior flap by turning it up thus increasing the length of a very short proximal tibial stump. The knee is thereby saved, allowing satisfactory use of a below-knee prosthesis. This technique is particularly applicable when the distal leg is normal and well vascularised. Five procedures have been undertaken. We present two illustrative cases.
Displaced supracondylar fracture in adults often require internal fixation. Plate fixation, requires soft tissue stripping resulting in devitalisation of bony fragments and this predisposes to risk of non union, infection and nerve injuries. This is the first report of a new technique, locked intramedullary transolecranon fossa nailing. In this technique the fracture is exposed through a limited posterior triceps splitting incision, keeping the soft tissue stripping to the minimum. The medullary canal is entered proximally through an anterior shoulder incision. A guide wire is inserted in an antegrade manner to enter the fracture site. The distal fragment is predrilled to create a tract with 3.2mm drill from proximal to distal, in such a way that the drill enters the olecranon fossa and then the proximal part of trochlea avoiding penetration of the elbow joint. The guide wire is then advanced into the tract in the distal segment. The medullary canal is reamed over the guide wire in anti-grade fashion with flexireamer. Utilising the standard antegrade technique, the nail is inserted and advanced under direct vision until tip of the nail is firmly seated in the trochlea. The proximal and distal locking are done in standard fashion. Postoperatively active mobilisation is encouraged. Four patients underwent this procedure. All the fractures healed in 3 months and at one year follow up the average arc of elbow motion is 120 degrees. There are no complications. Transolecranon fossa locked nailing is an available option to treat the displaced supracondylar fracture of humerus in adults.
Experience in the management of fourteen children with melorheostosis has been reviewed. The principal and presenting clinical features were unilateral soft-tissue contractures associated with inequality of limb length. In contrast to the disease in adults, pain occurred infrequently and was never intense. The average interval between the discovery of the clinical features and the correct diagnosis was six years. The distinctive radiographic feature in the child was an endosteal pattern of hyperostosis marked by streakiness of the long bones and spotting of the small. This differs from the usual subperiosteal or extracortical pattern of hyperostosis seen in adults. The surgical treatment of the contractures proved difficult and recurrence of the deformity was the rule. Distal ischaemia occurred when the chronically contracted and flexed joint was rapidly extended.
