Aims. The standard of surgical treatment for lower limb neoplasms had been characterized by highly interventional techniques, leading to severe kinetic impairment of the patients and incidences of phantom pain. Rotationplasty had arisen as a potent limb salvage treatment option for young cancer patients with lower limb bone tumours, but its impact on the gait through comparative studies still remains unclear several years after the introduction of the procedure. The aim of this study is to assess the effect of rotationplasty on gait parameters measured by gait analysis compared to healthy individuals. Methods. The MEDLINE, Scopus, and Cochrane databases were systematically searched without time restriction until 10 January 2022 for eligible studies. Gait parameters measured by gait analysis were the outcomes of interest. Results. Three studies were eligible for analyses. Compared to healthy individuals, rotationplasty significantly decreased gait velocity (-1.45 cm/sec; 95% confidence interval (CI) -1.98 to -0.93; p < 0.001), stride length (-1.20 cm; 95% CI -2.31 to -0.09; p < 0.001), cadence (-0.83 stride/min; 95% (CI -1.29 to -0.36; p < 0.001), and non-significantly increased cycle time (0.54 sec; 95% CI -0.42 to 1.51; p = 0.184). Conclusion. Rotationplasty is a valid option for the management of lower limb bone tumours in young cancer patients. Larger studies, with high patient accrual, refined surgical techniques, and well planned rehabilitation strategies, are required to further improve the reported outcomes of this procedure. Cite this article: Bone Jt Open 2023;4(11):817–824

Type BI rotationplasty is currently indicated for children with tumours of the proximal femur whereas type BIIIa rotationplasty is reserved for those in which the entire femur has to be removed. Our aim was to compare these two types of rotationplasty and determine whether the knee should be preserved in children with tumours of the proximal femur. We compared the post-operative complications, oncological outcome, range of movement, Enneking score and radiographs of six children, who had undergone type BI rotationplasty with those of 12 who had undergone type BIIIa rotationplasty. Patients with type BI rotationplasty had a mean Enneking score of 21.6 compared with 24.4 in those with type BIIIa rotationplasty, and worse mean results in all of the parameters investigated. We conclude that type BI rotationplasty has a worse functional outcome and more complications than type BIIIa rotationplasty in children under the age of ten years

Paediatric bone sarcomas around the knee are often amenable to either endoprosthetic reconstruction or rotationplasty. Cosmesis and durability dramatically distinguish these two options, although patient-reported functional satisfaction has been similar among survivors. However, the impact on oncological and surgical outcomes for these approaches has not been directly compared. We retrospectively reviewed all wide resections for bone sarcoma of the distal femur or proximal tibia that were reconstructed either with an endoprosthesis or by rotationplasty at our institution between June 2004 and December 2014 with a minimum two year follow-up. Pertinent demographic information, surgical and oncological outcomes were reviewed. Survival analysis was performed using the Kaplan-Meier method with statistical significance set at p<0.05. Thirty eight patients with primary sarcomas around the knee underwent wide resection and either endoprosthetic reconstruction (n=19) or rotationplasty (n=19). Groups were comparable in terms of demographic parameters and systemic tumour burden at presentation. We found that selection of endoprosthetic reconstruction versus rotationplasty did not impact overall survival for the entire patient cohort but was significant in subgroup analysis. Two-year overall survival was 86.7% and 85.6% in the endoprosthesis and rotationplasty groups, respectively (p=0.33). When only patients with greater than 90% chemotherapy-induced necrosis were considered, overall survival was significantly better in the rotationplasty versus endoprosthesis groups (100% vs. 72.9% at two years, p=0.013). Similarly, while event-free survival was not affected by reconstruction method (60.2% vs. 73.3% at two years for endoprosthesis vs rotationplasty, p=0.27), there was a trend towards lower local recurrence in rotationplasty patients (p=0.07). When surgical outcomes were considered, a higher complication rate was seen in patients that received an endoprosthesis compared to those who underwent rotationplasty. Including all reasons for re-operation, 78.9% (n=15) of the endoprosthesis patients required a minimum of one additional surgery compared with only 26.3% (n=5) among rotationplasty patients (p=0.003). The most common reasons for re-operation in endoprosthesis patients were wound breakdown/infection (n=6), limb length discrepancy (n=6) and periprosthetic fracture (n=2). Excluding limb length equalisation procedures, the average time to re-operation in this patient population was 5.6 months (range 1 week to 23 months). Similarly, the most common reason for a secondary procedure in rotationplasty patients was wound breakdown/infection, although only two patients experienced this complication. Average time to re-operation in this group was 23.8 months (range 5 to 49 months). Endoprosthetic reconstruction and rotationplasty are both viable limb-salvage options following wide resection of high-grade bony sarcomas located around the knee in the paediatric population. Endoprosthetic reconstruction is associated with a higher complication rate and may negatively impact local recurrence. Study of a larger number of patients is needed to determine whether the reconstructive choice affects survival

A rotationplasty is a unique surgical procedure used to reconstruct after resection of a tumor of the leg or a congenital defect. This procedure avoids phantom pain, limb length discrepancy and infections or implant related complications. The outcome is unusual for cosmesis but very functional. Background: Borggreve first described a rotationplasty in Germany in 1930 for a 12 year old patient whose knee was destroyed by tuberculosis. In 1950 Van Nes modified the procedure. Kotz and Saltzer described in 1982 the use of a modified version of a rotationplasty to treat malignant tumors of the distal femur. Case studies of two such patients will be presented. A 27 year old man had a non-metastic osteosarcoma of his distal femur at the age of five. He underwent chemotherapy and a rotationplasty. Six years after his operation a correction osteotomy was done. He is doing very well physically and mentally. He graduated business studies, went yearly on Alpine skiing on two legs, likes jogging and perceives no limitations in his life (MSTS, TESS, SF-36). A 24 year old man, 14 years after a Ewing-sarcoma of his hip. He underwent chemotherapy and radiation therapy. Thirteen years later he had a pathological fracture after playing soccer. He was treated with a total hip prosthesis without screening the malignancy. However the pathology of the specimen showed a postradiation sarcoma. He underwent a modified Van Nes rotationplasty (knee for hip and ankle for knee). Although is said that rotationplasty had a poor cosmesis and poor psychosocial acceptance, this is not our experience

Purpose. Rotationplasty was first described in 1930 by Borggreve for treatment of limb shortening with knee ankylosis after tuberculosis. In 1948, Van Nes described its use for management of congenital defects of the femur and in the 1980s, Kotz and Salzer reported on patients with malignant bone tumors around the knee treated by rotationplasty as an alternative to above-knee amputation. Currently, rotationplasty is one of the options for surgical management of lower extremity bone sarcomas in skeletally immature patients but alternative limb salvage techniques, such as the use of expandable endoprosthesis, are also available. Despite rather satisfactory functional results have been uniformly associated with rotationplasty, concern still exists about the potential psychological impact of the new body imagerelated to the strange appearance of the rotated limb. Results of rotationplasty for sarcomas of the distal femur over a 20-year period were analyzed, focusing on long-term survival, function, quality of life and mental health. Method. Retrospective study of 73 children who had a rotationplasty performed at two institutions between 1984 and 2007 for a bone sarcoma of the distal femur; 42 males and 31 females, mean age at surgery 8.7 yrs (range 3–17). Four patients were converted to transfemoral amputation due to early vascular complication; 25 eventually died of their disease (mean survival 34 months, range 4–127). The 46 remaining survivors were evaluated for updated clinical outcome, MSTS score, gait analysis, SF-36 score, quality of life interview and psychological assessment at mean follow-up of 15 yrs (range 3–23). Results. Overall survival was 64%. All the survivors were disease-free at last follow-up. Four patients required hardware revision for nonunion and subsequently healed. Three patients refused participation in the long-term follow-up study. Mean MSTS score was 79 (range 64–88). SF-36 score was obtained in 35 patients (age > 16); male patients showed a trend toward greater activity and vitality. Compared to age-group norms, rotationplasty scores were lower for physical activity level (p <0.05) and higher for general health perception (p = 0.05) and mental health (p < 0.05). Conclusion. Rotationplasty remains a durable reconstructive option with good long-term function and acceptable psychological impact for children with bone sarcomas of the distal femur

Introduction: Limb preserving surgery in children with bone sarcoma remains a significant challenge as most are expected to survive their disease and put significant functional loads on their reconstructed limbs. The most common reconstructions used for children with lower limb sarcomas are endoprosthetic replacements and rotationplasty. This study aimed to investigate and compare differences in the complications and functional outcomes between these two methods of reconstruction. Methods: This is a retrospective case control study of 12 rotationplasty patients and 12 patients who received EPR. Patients were selected at random from records provided by both centres and matched according to age at diagnosis, sex, site of disease and date of surgery. The Musculoskeletal Tumour Society (MSTS) score was used to evaluate functional outcome, and surgical complications were assessed qualitatively. Results: Five patients (42%) treated with endoprostheses experienced some form of post-operative surgical complication compared to three patients (25%) treated with rotationplasty and one patient from each group required an amputation to treat the complications. The average MSTS score was 22.7 in the EPR cohort and 18.9 in rotationplasty patients. This difference was statistically significant (p=0.05). Discussion: The study showed that patients who received EPR suffered more surgical complications than rotationplasty patients. However the results demonstrated superior functional outcomes in patients who received EPR. These results suggest that the functional benefit historically attributed to rotationplasty has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology. Conclusion: Our experience shows that patients with EPR are more likely to suffer more surgical complications but have similar, if not better functional outcomes compared to rotationplasty

Van Nes rotationplasty may be used for patients with congenital proximal focal femoral deficiency (PFFD). The lower limb is rotated to use the ankle and foot as a functional knee joint within a prosthesis. A small series of cases was investigated to determine the long-term outcome. At a mean of 21.5 years (11 to 45) after their rotationplasty, a total of 12 prosthetic patients completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires, as did 12 age- and gender-matched normal control participants. A physical examination and gait analysis, computerised dynamic posturography (CDP), and timed ‘Up & Go’ testing was also completed. Wilcoxon Signed rank test was used to compare each PFFD patient with a matched control participant with false discovery rate of 5%. There were no differences between the groups in overall health and well-being on the SF-36. Significant differences were seen in gait parameters in the PFFD group. Using CDP, the PFFD group had reduced symmetry in stance, and reduced end point and maximum excursions. Patients who had undergone Van Nes rotationplasty had a high level of function and quality of life at long-term follow-up, but presented with significant differences in gait and posture compared with the control group. Cite this article: Bone Joint J 2013;95-B:192–8

Introduction and Aims: Rotationplasty is a functional alternative to above knee amputation in very young patients with a lot of growth remaining and patients with large tumors necessitating excision of the thigh musculature. The development of gait following rotationplasty surgery was studied with serial gait and clinical analysis. Method: Five patients have been reviewed using three dimensional gait analysis incorporating temporal and spatial measures. A gait analysis was performed after the initial prosthetic fitting, six and 12 months postoperatively. The gait analysis included velocity, temporal/spatial measurements (velocity, cadence, step/stride length, pedobarographs), optical tracking and electromyography. Results: The kinematic and kinetic data revealed the rapid incorporation of knee flexion/extension (ankle dorsi/plantar flexion) into the gait cycle. Electromyography also showed the gastrocnemius to be simulating the quadriceps and the tibialis anterior to mimic the hamstrings in terms of firing time in the stance and swing phase of the rotated limb. Propulsive forces on the kinetic analysis suggest further gait maturation can occur for several years following this procedure. Conclusion: Children adapt very well to the altered anatomy following rotationplasty and using gait analysis confirms the new role of the altered muscles. Weakness about the hip remains a major concern that needs to be addressed with physiotherapy for several years postoperatively

Introduction: Primary bones sarcomas account for 5% of childhood cancers; however the introduction of neo-adjuvant chemotherapy and the development of surgical techniques have resulted in reduced mortality and a longer length of survival. Consequently improving post operative functional outcomes has become an important focus of research. The aim of this study was to investigate and compare differences in the complications and functional outcomes of EPR and rotationplasty in skeletally immature patients. Methods: This is a retrospective case control study of twenty-four patients, of whom twelve received rotation-plasty and twelve received EPR. Patients were selected at random and matched according to age at diagnosis, sex, site of disease and date of surgery. The Musculoskeletal Tumour Society (MSTS) score was used to evaluate functional outcome, and surgical complications were assessed qualitatively. Results: Five patients (42%) treated with endoprosthe-ses experienced some form of post-operative surgical complication compared to three patients (25%) treated with rotationplasty. However this difference was not found to be statistically significant. The average MSTS score in the EPR cohort was 22.7 and 18.9 in rotation-plasty patients. Mann Whitney U testing confirmed this difference to be statistically significant (p=0.05). Discussion: The study showed that patients who received EPR suffered more surgical complications than rotationplasty patients. However the results demonstrated superior functional outcomes in patients who received EPR. The theoretical benefit historically attributed to rota-tionplasty lies in the provision of a functional and durable hinge joint, however these results suggest that this advantage has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology. Conclusion: Our experience shows that patients with EPR are more likely to suffer more surgical complications but have similar, if not better functional outcomes compared to rotationplasty

Failure of massive knee endoprostheses implanted for malignant tumours of the distal femur in children presents a difficult problem. We present the results of rotationplasty undertaken under these circumstances in four boys. They had been treated initially at a mean age of 9.5 years for a stage-IIB malignant tumour of the distal femur by resection and implantation of a massive knee endoprosthesis. After a mean period of eight years and a mean of four operative procedures, there was failure of the endoprosthesis because of aseptic loosening in two and infection in two. Function was poor with a mean Musculoskeletal Tumor Society score of 7.5/30, and considerable associated psychological problems. At a mean follow-up of 4.5 years after rotationplasty there was excellent function with a mean score of 27.5/30 and resolution of the psychological problems

Above-knee amputation has been the traditional treatment for osteosarcoma of the proximal tibia. Recent advances in chemotherapy have encouraged the development of limb-salvage techniques. Van Nes rotationplasty for malignant lesions of the distal femur has increased in popularity as a reconstructive technique, but no similar procedure has been described for lesions of the proximal tibia. We have developed a modified rotationplasty for this lesion and have performed it in four children. The surgical technique, postoperative management and results of the procedure are described. Two patients had delayed wound healing. No other complications have developed and our patients were disease-free at follow-up, while the appearance of the leg was well accepted by the patients and their parents. This procedure is a useful addition to the armamentarium of the tumour surgeon for the treatment of malignant lesions of the proximal tibia

Rotationplasty, or the Van Nes procedure, is a surgical option for reconstruction of the lower extremity after resection of a malignant bone tumor in predominantly skeletally immature patients. The procedure usually involves resection of the femur and knee joint en bloc. Virtually all soft tissues, including skin around the tumor, are excised, and the sciatic nerve is preserved. The vessels can be resected and re-anastamosed or preserved. The leg and foot are rotated 180 degrees and reattached, preserving and/or restoring the nerves and blood supply. The foot and ankle which face posteriorly, then function as a knee joint in a custom-made prosthesis. Although this procedure has been successfully performed for many years, patients and families cite cosmesis as a major consideration when making this decision. The lack of knowledge and understanding of the functionality, the psychosocial adjustment, and the quality of life with the rotationplasty, also, present challenges for families with respect to acceptance of this surgical choice. Two case studies will be discussed to demonstrate the biopsychosocial elements of this procedure. These two individuals, 2.5 years and 24 years post-rotationplasty respectively, have attained success in their personal and professional lives, and they have willingly and enthusiastically shared their experiences with patients and families considering this surgical option. Using Roy’s adaptation model, this presentation will focus on adopting positive role modeling to enhance adaptive strategies needed by patients and families to guide their decision making

The operative technique for combined fusion of the knee and rotationplasty of the limb in the management of congenital deficiency of the femur is presented. The technique described allows earlier definitive prosthetic fitting of a child with proximal femoral deficiency; it has reduced the number of operative procedures needed to obtain the optimal function from that deficient limb; and it has enabled these procedures to be performed at an earlier age. The technique differs from those previously described and represents a significant improvement in management of the patient with femoral deficiency

Type IIb, so called mobiled pseudoarthrosis according to Paley classification, is characterized by congenital pseudoarthrosis of proximal femur with an isolated small and stiff femoral head. We are unable to create a moveable hip joint but appropriate length of the affected extremity can be reached by gradual lengthening. In previous classification it is known as Type Aitken C or Pappas III. Type IIIa, with diaphysial deficiency of femur, corresponds to Type D according to Aitken or to Type I and II according to Pappas. In Type IIIa, the knee joint is developed and functional with the ROM more than 45 degrees. In Type IIIb the knee joint is more or less stiff and functionally unuseable. These three groups present the most severe congenital short femur deformities, but their occurrence is fortunately very seldom – less than 1 in 300 thousand live births. Among 41 cases of congenital short femur Pappas I–IV which were collected during 30 years from the Czech population of 10 million – Pappas I was seen in one case, Pappas II in five cases, Pappas III in 16 cases and Pappas IV in 19 cases. From the 16 cases of Pappas III deformity was found in three of them – stiffness of isolated femoral head was found and these three patients were added to this group. Method of Treatment: In Type IIb we use complex treatment consisting of six consecutive steps:. Distraction of the distal part of femur up to acetabular level. Connection between head and diaphysis. First femoral lengthening. Lengthening of the tibia. Contralateral epiphysiodesis around the knee. Plastic surgery. Lengthening between 15 and 39 cm was reached. In Type IIIa, ilio-femoral fusion (knee-for-hip procedure) was performed in five cases. The functional results are excellent. There was no need for Syme amputation or rotationplasty. The prerequisite is at least 60 degrees arc of motion in the knee joint. Severe restricted ROM in the knee joint may lead to pseudoarthrosis. In Type IIIb (2 cases), the residual fragment of distal femur with unfunctional knee joint was stabilized in socket formed after pelvic osteotomy in the level of original acetabulum. The removal of telescopic proximo-distal movement stabilized the supportive function of the extremity

The June 2012 Oncology Roundup. 360. looks at: avoiding pelvic hemipelvectomy; proximal femoral metastasis; extendible prostheses; rotationplasty; soft-tissue sarcomas; osteosarcoma of the pelvis; recurrent chondrosarcoma ; MRI and the differentiation between benign and malignant lesions; and malignant fibrous histiocytoma

Parosteal osteosarcoma is an uncommon tumour. Different methods of surgical treatment have been reported. Aim of this study was to investigate differences in outcome after biological and prosthetic reconstruction. Since August 1969, 28 patients have been treated at our institution. Average age was 26 years, range 15 to 59 years. Patient data was retrospectively reviewed within the prospective database of the Vienna Tumour Registry. Average follow-up was 133.9 months, range 8.4 to 382.6 months. Two patients died of disease 8.4 and 81.4 months after operation, respectively, another patient died due to unrelated causes 330.4 months postoperatively. All surviving patients were followed for a minimum of 3.6 months. Location of the lesion was the distal femur (19), proximal humerus (four), proximal tibia (three), mid-diaphyseal and proximal femur (one each). In 12 patients endoprosthetic reconstruction was indicated. Biological reconstruction was performed in 11 patients. Three patients underwent rotationplasty, two patients were amputated. Eight of 12 patients with endoprostheses have been revised, five have had multiple revisions. Causes for revision were bushing wear (four), aseptic loosening (four), infection (three) and periprosthetic fracture (one). There was no local recurrence in the endoprosthetic group. Two of 11 patients with biological reconstruction underwent revision due to pseudarthrosis and femoral fracture, respectively. There were two cases of local recurrence requiring secondary amputation. Two patients with rotationplasty underwent revision for wound healing disturbance and thrombectomy, respectively. Three patients developed lung metastases, leading to death of disease in two cases of amputation and rotationplasty. One patient with endoprosthetic reconstruction was alive 129.0 months after pulmonary metastasectomy. Functional outcome was satisfactory in all patients; there were no significant differences between patients with endoprosthetic or biological reconstruction. Biological reconstruction showed less revisions compared to endoprostheses, however, exact preoperative planning is required to obtain clear margins of resection

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision. Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores. . This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs. Cite this article: Bone Joint J 2015;97-B:1284–90

The purpose of the study was to evaluate the functional outcome of different limb salvage procedures for osteosarcoma about the knee. A selection of patients who have undergone limb salvage procedures for osteosarcoma about the knee were invited to join the study. Medical and operation notes were reviewed along with recent radiographs of the involved limb. Patients completed the Musculoskeletal Tumour Society functional questionnaire and underwent a gait analysis assessing walking and running. Most patients had stage 2B osteosarcoma involving either the proximal tibia or distal femur. Limb salvage procedures included arthrodesis, allograft reconstruction, endoprosthesis and rotationplasty. All patients scored highly (> 70 %) on the MSTS questionnaire except the arthrodesis that scored 57 %. The gait analysis revealed some subtle changes with a quadriceps-sparing gait in the endoprosthesis, mild foot drop in the proximal tibial allograft and a lateral lean of the trunk over the ipsilateral limb in the rotationplasty. The arthrodesis had an obvious straight leg gait with subtle pelvic hiking to assist foot clearance. While analysis of walking was close to normal most patients were unable to obtain a double float and run. This study shows that limb salvage procedures tailored to each individual case can result in an excellent functional outcome with close to normal gait and high MSTS scores

Aims

Surgical limb sparing for knee-bearing paediatric bone sarcoma is considered to have a clinically significant influence on postoperative function due to complications and leg-length discrepancies. However, researchers have not fully evaluated the long-term postoperative functional outcomes. Therefore, in this study, we aimed to elucidate the risk factors and long-term functional prognosis associated with paediatric limb-sparing surgery.