A 37-year-old male patient with no personal history of functional interest presented to the emergency department of our hospital due to a mass in the posterior compartment of the left lower limb of years of evolution, painless until the last 3 weeks of pain, impotence
On physical examination, the patient presented a large mass in the posterior region of the left atrium measuring approximately 15 cm in diameter, with dismissal of the posterior and lateral compartments.
The patient also complained of paresthesia and dysesthesia in the affected limb and hyperesthesia in the pulp of the first toe and in the peroneal region.
The vascularisation of the limb was consistent, with preserved popliteal, posterior tibial and pedial pulses.
However, we found greater coldness in the left foot compared to the contralateral foot.
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Trucut of the mass was performed with pathological results of high grade fusocellular sarcoma (synovial sarcoma).
Magnetic resonance imaging (MRI) revealed the presence of a large mass in the left side affecting the entire thickness of the soleus muscle, markedly heterogeneous, multinodular and polylobulated, 14 cm diameter.
In the posterior part, the lesion compresses and displaces the muscle belly of the internal and external twins, with which it contacts without fatty planes, and in the anterior part with the common tibial flexor popliteus.
Anteriorly located, the mass of the upper pole of the first flexor.
With respect to bone structures we observed a close relationship with the tibial diaphysis and although the fat planes are maintained, the thickness of the tissue interposed between both structures is less than 1cm.
The fibula includes the fibula semitendinosus, an extension of 12 cm. Despite the close relationship of the tumor with the tibia and fibula, we did not observe signs suggestive of bone loss.
Regarding the vascular structures, we appreciate how the upper pole of the tumor contacts the popliteal artery at the level of its bifurcation from the exit of the anterior tibial trunk, going to encompass the distally perineum vessels.
In summary, this is a tumor in the left soleus muscle of 14 cm in diameter, suggesting sarcoma with signs of vascular inactivity and adjacent muscles.
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The patient underwent surgery under general anesthesia and the surgery was performed by a single surgical team that performed both tumor resection and subsequent reconstruction.
We began with the plantar flap dissecting a Künstcher B3 fillet flap (6) and subsequently with infracondylar amputation including the posterior tibial cortex.
We performed terminoterminal anastomosis (T-T) to the popliteal artery and both saphenous and neurorrhaphy between external popliteal sciatic and posterior tibial.
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In the immediate postoperative period, the patient did not present any hemodynamic alteration and the flap and its formation were favorable without the need for microsurgical revision in the days after the intervention.
The anatomopathological result of the resected specimen was a biphasic synovial sarcoma with a high degree of 15 cm of maximum diameter in the thickness of the muscle tissue, with respected surgical margins (tumour of 1.5 cm of the proximal surgical edge).
There was no evidence of bone tissue infiltration.
The patient was discharged 30 days after surgery.
We carried out a weekly follow-up until achieving optimal healing to start with orthopedic treatment.
At 60 days, the patient was ambulation with a transtibial prosthesis type PTB (patellartendon-Bengineering PubMed) with endodynamic foot system with complete sensitivity in the stump.
The total follow-up was 7 months after surgery.
Two years after the intervention, the patient continues to be monitored by the Ongoing Rehabilitation Services of our hospital, which will proceed to the change protuberance according to their protocol every two years.
To date, no evidence of local recurrence has been found.
