<title>1. INTRODUCTION</title> <p>Before the era of endoprosthetic devices,
rotationplasty, which was introduced in 1974 by Salzer et al. [##UREF##0##1##] in the surgery of
malignant bone tumors and modified by Winkelmann [##UREF##1##2##, ##REF##8649733##3##] was a viable alternative to
amputation. Despite many authors favouring limb saving procedures today,
rotationplasty obtains excellent functional and psychosocial results [##REF##1918120##4##, ##REF##11110135##5##].
Whereas nowadays in most patients limb-salvage procedures are performed
successfully, rotationplasty can be recommended in tumors with an extensive
soft tissue component, as a salvage procedure in the case of a failed limb
salvage procedure [##REF##11110135##5##], and in very young children as an alternative to growing
prostheses [##UREF##2##6##].</p> <p>It is a common question from
physicians (especially oncologists), if there is an age limitation for
rotationplasty. We know that even very young children can be treated with a
rotationplasty with excellent functional results [##UREF##1##2##, ##REF##8649733##3##, ##UREF##2##6##], but an upper age
limitation is difficult to determine. It depends on the biological age of the
patient, the range of motion in the ankle joint, the stage of tumor disease,
and the extension of the tumor. To our knowledge there are no reports about
rotationplasty in older patients. The current-case report describes the
perioperative complications and the short-term followup in two patients and a long-term functional result in one patient with an A1-rotationplasty.</p>
<title>2. MATERIALS AND METHODS</title> <p>Three patients without any comorbidities
(e.g., diabetes and atherosclerosis) with an age over 60 years (mean 65, range
62–70) were treated
with an AI rotationplasty according to Winkelmann [##REF##8649733##3##] instead of an above-knee amputation (##TAB##0##Table 1##). This
type of rotationplasty is applicable for patients with a tumor in the distal
part of the femur or thigh. The osteotomy is performed in the proximal third of
the femur, distal to the lesser trochanter, and in the proximal part of the
tibia, distal to the tibial tuberosity. The foot is rotated 180°, and the tibia
is reattached to the proximal femur by a plate osteosynthesis (##FIG##0##Figure 1##). The
femoral vessels can be resected and reanastomosed or can be preserved in the case
of absent tumor infiltration (##FIG##1##Figure 2##). The indication for rotationplasty was
an extensive soft tissue sarcoma of the quadriceps muscle in two patients (1
malignant schwannoma grade III, 1 dedifferentiated liposarcoma). Patient number
1 was treated previously by 3 intralesional resections in other hospitals.
Because of local recurrence, a marginal resection combined with adjuvant
radiotherapy with 60 Gray was performed in our department. However, 9 months
postoperatively a further local recurrence with synchronous lung metastases
developed. Patient number 2 with an additional intraarticular tumor extension to
the knee had no prior surgery (Figures ##FIG##2##3(a)## and ##FIG##2##3(b)##). In these 2 patients,
rotationplasty was indicated because of tumor infiltration of the whole
quadriceps muscle. Therefore, limb sparing surgery (e.g., with a tumor
prosthesis) with good functional results regarding stabilization and extension
of the knee was not possible any more. The third patient had a malignant
fibrous histiocytoma of the popliteal fossa with an extensive infiltration of
the popliteal vessels, which was treated by an intralesional resection one month
before in another hospital. The followup ranged from 6 months to 15 years. At
final followup, two patients were alive without evidence of disease. Patient number
1 died of disease due to lung metastases 12 months postoperatively.</p> <p>In this retrospective study
the patients charts were evaluated regarding intra- and postoperative
complications and the functional results evaluated to Enneking et al. [##REF##8425352##7##]. Data about the functional results
were obtained by a questioning. In patient number 3, an electromyography of the
involved and uninvolved limb was performed.</p>
<title>3. RESULTS</title> <p>No patient experienced a local recurrence.
Bone healing after osteosynthesis of the tibia and proximal femur was achieved
in all cases (##FIG##0##Figure 1##). Regarding postoperative complications, patient number
1 developed a thrombosis of the femoral vein 6 months postoperatively resulting
in moderate lymphedema. All patients received full-dose anticoagulation for 1
week and prophylaxis for deep venous thrombosis until the final prosthesis was
fitted. No wound healing complications occurred.</p> <p>Two patients needed a cane for
a gait distance of more than 200 meters. The walking distance even with support
was reduced but ranged from 500 to 2000 meters. However, no patient experienced
pain and needed analgesics. The range of motion of the ankle joint was not
restricted (##FIG##3##Figure 4##). In patient number 2 no signs of degenerative joint
disease of the ankle joint could be observed 15 years postoperatively. However,
osteopenia due to the limited loading of the rotated leg was obvious (Figures ##FIG##4##5(a)## and ##FIG##4##5(b)##). The mean Enneking score was 19 of 30 points. All patients were
amenable to having the same surgery again if necessary.</p> <p>Electromyography in patient
number 2 showed that the tibialis anterior muscle converted to a powerful
flexor of the ankle joint. The soleus muscle as an extensor of the ankle joint
showed normal activity electromyography, but the muscle activity of the lateral
gastrocnemius muscle was slightly and of the medial gastrocnemius muscle
severely reduced. The peroneal muscles with a stabilizing function of the ankle
joint showed only a slightly reduced activity. In summary, electromyography
showed despite the reduced activity of the medial gastrocnemius muscle a good
adaptation of the muscles to the new function.</p>
<title>4. DISCUSSION</title> <p>Rotationplasty was introduced by Salzer et al. [##UREF##0##1##]
in the surgery of malignant bone tumors of the distal femur as an alternative
to an above-knee amputation in young patients. In the following study,
Winkelmann [##UREF##1##2##, ##REF##8649733##3##] widened the indication for rotationplasty for
patients with tumors located at the proximal or even entire femur and the
proximal tibia. Many studies show the good functional results and suggest good psychosocial
acceptance by patients [##UREF##3##8##, ##REF##14612629##9##]. In contrast to an above-knee amputation,
rotationplasty allows the patients to actively control the neo-knee mechanism,
which results in a coordinated gait pattern [##REF##14612629##9##]. The muscles of the ankle or neo-knee
joint are able to adapt very fast to the changed anatomic condition [##REF##14612629##9##]. Further
studies underline that an adaption of the ankle joint to the changed
biomechanic situation is possible and degenerative changes of the joint could
be excluded in a long-term followup ranging between 10 and 15 years in
predominantly young or middle-aged patients [##REF##17162522##10##]. Nevertheless, there have been
concerns if this adaptation process is at all possible in older patients. The
long-term followup of patient number 2 in the current study could exclude a
relevant progressive arthrosis in the ankle joint 15 years postoperatively
without having the same activity level as younger patients.</p> <p>The complication rate of
rotationplasty has been reported to be low [##UREF##1##2##–##REF##1918120##4##]. The worst complications are a
failure of the vascular anastomosis and a pseudarthrosis of the osteosynthesis
in A1 rotationplasty [##UREF##1##2##]. To our knowledge rotationplasty has not been reported
in patients over 60 years so far. It could be assumed that the complication
rate in older patients would be higher, especially regarding wound healing
problems and a failure or thrombosis of the vascular anastomosis because of
arteriosclerosis. Indeed, a thrombosis of the femoral vein occurred in one out
of three patients 6 months postoperatively without relevant clinical
complaints. However, thrombosis after rotationplasty has been reported even in
younger patients [##REF##1499380##11##]. Furthermore, the perioperative complication rate in
older patients with multiple morbidities undergoing an above-knee amputation
due to, for instance, arteriosclerosis or diabetes has been reported to be high
[##REF##12844082##12##]. Common complications include stump healing problems and cardiovascular morbidities
[##REF##12844082##12##, ##REF##7827880##13##]. In our study wound healing complications were not observed. To our
knowledge there have been no reports analyzing the complication rate of
above-knee amputations due to a sarcoma in older patients.</p> <p>Regarding the functional
results of rotationplasty, Hillmann et al. [##REF##10682727##14##] reported that the age at the
time of operation showed a distinct influence on gait, walking ability, and the
Enneking score. Younger patients were better able to adapt to the altered
anatomical and functional conditions.
Our case report could show that an old patient has more difficulties to adapt to the new
anatomical situation, in spite of the fact that electromyography showed no
marked differences in comparison to younger patients in one patient and the
range of motion of the neoknee joint was not limited, the functional results of
our patients were poorer (Enneking score of 19 out of 30 points) compared to
younger patients reported by Hillmann et al. [##REF##10682727##14##]. They reported an average
score of 23.9 out of 30 points in 43 patients with a mean age of 17.8 years.
Functional results were poorer in our patients
because of a reduced walking distance and by the use of a walking aid for
longer distances. However, an above-knee amputation in older patients with comorbidities
(diabetes, vascular diseases) is associated with poorer functional results in
comparison to younger patients also [##REF##12844082##12##, ##REF##16102618##15##]. Frequently, these patients are not
able to walk or do not use their exoprosthesis. Others can walk with the help
of crutches for short distances only [##REF##12844082##12##, ##REF##16102618##15##].</p> <p>It is well known that the
energy demand for prosthetic gait is higher in above-knee amputations compared
to below-knee amputations [##REF##8909359##16##]. Therefore, rotationplasty could offer a
functional improvement in comparison to an above-knee amputation even in older
patients because the knee joint is “preserved.” Previous studies showed that patients
with a rotationplasty walk more efficiently according to the measurement of
consumption of oxygen in comparison to patients with an above-knee amputation
[##REF##2777845##17##]. These facts should be transferable as well for older patients, in whom an
efficient use of the energy demand is more important because of an
age-dependent limitation of the cardiovascular system.</p> <p>It has to be emphasized that
only one patient has a long-term follow-up. Therefore, the results from this
patient can not be generalized. The followup of the other two patients is too
short to evaluate the functional and radiological results. Furthermore,
rotationplasty should not be performed in patients with metastatic disease and
a poor prognosis (patient number 1) because of the prolonged rehabilitation
process after this surgical procedure. Nevertheless, we believe that this case
report is important to show that rotationplasty is a possible procedure even in
the elderly. Larger retrospective studies or even prospective studies are
needed to examine this topic and to compare patients with rotationplasty
against an above-knee amputation.</p>
<title>5. CONCLUSION</title> <p>In conclusion, it can be stated that rotationplasty
is an alternative to above-knee amputation in older patients if limb-sparing
surgery is not possible. However, the functional results might be not
comparable to younger patients, who regain mainly normal walking abilities and
sporting abilities. Prospective studies with a larger patient group have to
evaluate, if rotationplasty offers a functional advantage against an above-knee
amputation in older patients.</p>
<p>Recommended by Ajay Puri</p> <p>
<italic>Purpose</italic>. Rotationplasty has proven its efficacy in the treatment of malignant bone tumors of the lower extremity in predominantly young patients. To our knowledge this procedure has not been reported in patients over 60 years before. <italic>Materials and Methods</italic>. 3 patients over 60 years with an A1-rotationplasty because of a sarcoma were included in this study. Complications and functional results were recorded. In one patient an electromyography was done. <italic>Results</italic>. Despite electromyography showing good adaptation of the muscles to the altered function, the functional results of these three patients were limited. two out of three patients needed a cane for walking distances over 200 meters. No secondary amputation was necessary. <italic>Discussion</italic>. Our study demonstrates that rotationplasty is an alternative to an above-knee amputation in older patients but with poorer functional results in comparison to younger patients. However, limb-salvage surgery should be preferred whenever possible.</p>
<fig id="fig1" position="float"><label>Figure 1</label><caption><p>An anterior-posterior radiograph showing an A1-rotationplasty 12 years postoperatively without signs of pseudarthrosis.</p></caption></fig> <fig id="fig2" position="float"><label>Figure 2</label><caption><p> An intraoperative
picture after resection of a dedifferentiated liposarcoma of the distal part of
the thigh. The femoral vessels could be preserved because of no tumor
infiltration. See below the vessels the sciatic nerve.</p></caption></fig> <fig id="fig3" position="float"><label>Figure 3</label><caption><p>(a) A coronar magnetic resonance imaging (T2-weighted) showing the tumor infiltration of the knee. (b) An axial T2-weighted sequence showing the tumor extension of the whole quadriceps muscles.</p></caption></fig> <fig id="fig4" position="float"><label>Figure 4</label><caption><p>Photographs 6 months postoperatively showing an unrestricted dorsalextension and plantarflexion of the ankle.</p></caption></fig> <fig id="fig5" position="float"><label>Figure 5</label><caption><p>(a) An anterior-posterior
radiograph showing the ankle without relevant signs of arthrosis 1 years
postoperatively. Osteopenia due to the limited exposure of the leg. (b) An anterior-posterior and lateral
radiograph showing the ankle 15 years postoperatively without relevant signs of
arthrosis.</p></caption></fig>
<table-wrap id="tab1" position="float"><label>Table 1</label><caption><p>Patient's details.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">No.</th><th align="center" rowspan="1" colspan="1">Gender</th><th align="left" rowspan="1" colspan="1">Age at operation (years)</th><th align="left" rowspan="1" colspan="1">Diagnosis</th><th align="left" rowspan="1" colspan="1">Site of tumor</th><th align="center" rowspan="1" colspan="1">Metas-tasis</th><th align="left" rowspan="1" colspan="1">Prior operations</th><th align="center" rowspan="1" colspan="1">Radio-therapy</th><th align="center" rowspan="1" colspan="1">Chemo- therapy</th><th align="center" rowspan="1" colspan="1">Followup (months)</th><th align="center" rowspan="1" colspan="1">Stage of disease</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">male</td><td align="left" rowspan="1" colspan="1">62</td><td align="left" rowspan="1" colspan="1">Malignant schwannoma GII-III</td><td align="left" rowspan="1" colspan="1">Ventral thigh</td><td align="center" rowspan="1" colspan="1">Lung</td><td align="left" rowspan="1" colspan="1">Intralesional resection</td><td align="center" rowspan="1" colspan="1">Yes</td><td align="center" rowspan="1" colspan="1">No</td><td align="center" rowspan="1" colspan="1">12</td><td align="center" rowspan="1" colspan="1">DOD</td></tr><tr><td align="left" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">female</td><td align="left" rowspan="1" colspan="1">70</td><td align="left" rowspan="1" colspan="1">Liposarcoma GIII</td><td align="left" rowspan="1" colspan="1">Ventral thigh</td><td align="center" rowspan="1" colspan="1">No</td><td align="left" rowspan="1" colspan="1">No</td><td align="center" rowspan="1" colspan="1">No</td><td align="center" rowspan="1" colspan="1">No</td><td align="center" rowspan="1" colspan="1">6</td><td align="center" rowspan="1" colspan="1">NED</td></tr><tr><td align="left" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">female</td><td align="left" rowspan="1" colspan="1">63</td><td align="left" rowspan="1" colspan="1">Malignant fibrous histiocytoma GIII</td><td align="left" rowspan="1" colspan="1">Popliteal fossa</td><td align="center" rowspan="1" colspan="1">No</td><td align="left" rowspan="1" colspan="1">Intralesional resection</td><td align="center" rowspan="1" colspan="1">No</td><td align="center" rowspan="1" colspan="1">Yes</td><td align="center" rowspan="1" colspan="1">186</td><td align="center" rowspan="1" colspan="1">NED</td></tr></tbody></table></table-wrap>
<table-wrap-foot><fn><p>DOD: Dead of disease, NED: No evidence of disease.</p></fn></table-wrap-foot>
<graphic xlink:href="SRCM2008-402378.001"/> <graphic xlink:href="SRCM2008-402378.002"/> <graphic xlink:href="SRCM2008-402378.003"/> <graphic xlink:href="SRCM2008-402378.004"/> <graphic xlink:href="SRCM2008-402378.005"/>
[{"label": ["1"], "surname": ["Salzer", "Knahr", "Kotz", "Kristen"], "given-names": ["M", "K", "R", "H"], "article-title": ["Treatment of osteosarcomata of the distal femur by rotation-plasty"], "italic": ["Archives of Orthopaedic and Traumatic Surgery"], "year": ["1981"], "volume": ["99"], "issue": ["2"], "fpage": ["131"], "lpage": ["136"]}, {"label": ["2"], "surname": ["Winkelmann"], "given-names": ["W"], "article-title": ["Hip rotationplasty for malignant tumors of the proximal part of the femur"], "italic": ["The Journal of Bone & Joint Surgery"], "year": ["1986"], "volume": ["68"], "issue": ["3"], "fpage": ["362"], "lpage": ["369"]}, {"label": ["6"], "surname": ["Hardes", "Gosheger", "Vachtsevanos", "Hoffmann", "Ahrens", "Winkelmann"], "given-names": ["J", "G", "L", "C", "H", "W"], "article-title": ["Rotationplasty type BI versus type BIIIa in children under the age of ten years\u2014should the knee be preserved?"], "italic": ["The Journal of Bone & Joint Surgery"], "year": ["2005"], "volume": ["87-B"], "issue": ["3"], "fpage": ["395"], "lpage": ["400"]}, {"label": ["8"], "surname": ["R\u00f6dl", "Pohlmann", "Gosheger", "Lindner", "Winkelmann"], "given-names": ["RW", "U", "G", "NJ", "W"], "article-title": ["Rotationplasty\u2014quality of life after 10 years in 22 patients"], "italic": ["Acta Orthopaedica"], "year": ["2002"], "volume": ["73"], "issue": ["1"], "fpage": ["85"], "lpage": ["88"]}]
Sarcoma. 2008 Jul 29; 2008:402378