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Rotationplasty
Rotationplasty
Rotationplasty
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Rotationplasty, commonly known as a Van Nes rotation or Borggreve rotation, is a type of autograft wherein a portion of a limb is removed, while the remaining limb below the involved portion is rotated and reattached. This procedure is used when a portion of an extremity is injured, or affected by a disease such as cancer.[1]

The procedure is most commonly used to transfer the ankle joint to the knee joint following removal of a distal femoral bone tumor, such as osteosarcoma. The limb is rotated because the ankle flexes in the opposite direction compared to the knee. The benefit to the patient is that they have a functioning knee joint to which a prosthetic can be fitted, providing them with better mobility.

History

[edit]

Rotationplasty was first performed by Joseph Borggreve in 1927.[2] He performed the procedure on a 12-year-old boy who suffered from tuberculosis. However, the procedure was not well known until 1950, when Dutch orthopedist Cornelis Pieter van Nes (1897–1972) reported the results of rotationplasty procedures.[3] He became well known for establishing the procedure. Since then, many surgeons have performed modified versions of rotationplasty and have had great success.[citation needed]

Originally, rotationplasty was performed to treat infections and tumors around the knee. It was also a common treatment for osteosarcoma.[4] While it is still being used to treat their complications, rotationplasty is also used to treat growing children who have been diagnosed with tumors around the knee.[5] Rotationplasty is also performed on children with congenital femoral deficiencies. Those deficiencies cause "unstable hip joint[s] and a femur that is 50% shorter than the contralateral, normal femur."[6] This procedure gives rotationplasty patients the ability to have the use of both feet and allows them to continue living an active lifestyle.[citation needed]

Procedure

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In the actual procedure, the bone affected by the tumor, as well as a small part of the healthy femoral and occasionally tibia bone, is removed. A portion of the leg removed; the ankle joint is then turned 180 degrees and is reattached to the thigh. They are held together by plates and screws until they have healed naturally. The surgery can take anywhere from 6 to 10 hours, with a day or two in intensive care.[7] The leg is kept in a cast for 6 to 12 weeks. After the leg has sufficiently healed, the leg can be fitted for a prosthetic.[8]

Advantages and disadvantages

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Advantages

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Rotationplasty allows the use of the knee joint, whereas amputation would result in loss of that joint. Therefore, it provides a better attachment point and range of motion for a prosthetic limb. As a result, children who have had rotationplasty can play sports, run, climb, and do more than would be possible with a jointless prosthetic. After the procedure, the leg is durable; patients do not typically have to undergo additional surgeries.[5]

Disadvantages

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Rotationplasty can result in poor circulation throughout the leg, infection, nerve injuries, bone healing complications, and fracture of the leg.[9]

Quality of life

[edit]

A 2002 study measured life contentment and quality of life in 22 patients who had been recipients of the rotationplasty procedure at least 10 years before. They found that those patients that were younger when the procedure was performed were happier with their lives. It was also found that 8 of the 22 had to have a total of 21 surgical revisions performed in the 10 years. In comparison to the general population, the patients had a higher percentage of quality of life, 83% compared to 75%. Overall, the patients were more content with different aspects of their lives than the general population.[10]

References

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Rotationplasty

View on Grokipedia
from Grokipedia
Rotationplasty is a specialized orthopedic surgical procedure that involves the resection of a diseased section of the lower extremity, typically the and surrounding , followed by a 180-degree rotation of the distal (shin, ankle, and foot) and its reattachment to the proximal , effectively transforming the ankle into a functional for prosthetic use. This limb-salvage technique is most commonly performed as an alternative to above- in pediatric patients with sarcomas, such as or , located near the , allowing preservation of the patient's own limb tissues while enabling high levels of mobility and activity. The procedure was first described in 1930 by German surgeon Joseph Borggreve for treating femoral deficiency associated with of the , and it was later adapted by C.P. Van Nes in 1950 for congenital . Its application to oncologic resections began in 1981, popularized by Salzer et al. for skeletally immature patients requiring or proximal resection due to malignant tumors. Today, rotationplasty is indicated not only for bone cancers but also for certain congenital deformities, traumatic injuries, or severe infections affecting the lower limb, provided the and distal leg neurovascular structures remain intact and functional. It is particularly advantageous in growing children under age 12, as it accommodates natural bone lengthening without the need for frequent reconstructive revisions. During , performed under general and lasting 4 to 10 hours, the tumor-affected segment—including the distal , , and proximal —is excised with margins of healthy tissue to ensure oncologic clearance, after which the lower leg is rotated posteriorly and fixed to the remaining using plates, screws, or other osteosynthesis methods, often involving transfers for stability. Postoperatively, patients typically spend 1 to 2 days in intensive care followed by a stay of several days, with requiring 3 to 6 months; intensive is essential to adapt the ankle's flexion as the new motion and to fit a custom that accommodates the rotated foot. Key benefits include superior functional outcomes compared to traditional or endoprosthetic reconstruction, such as reduced pain, avoidance of prosthetic failures, and the ability to participate in sports—studies report that up to 85% of patients engage in athletic activities without significant impairment. Risks, however, include , nerve or vascular , delayed union of the bone, and , necessitating surgery at specialized centers experienced in pediatric and limb reconstruction. With proper rehabilitation, most patients achieve independent ambulation within 3 to 6 months and resume normal activities by 6 to 12 months, highlighting rotationplasty's role as a durable, biologic solution for complex lower limb salvage.

Overview and Indications

Definition and Purpose

Rotationplasty is an autologous that involves resecting a portion of the lower limb around the , typically including the distal , , and proximal , followed by a 180-degree external rotation of the remaining lower segment and its reattachment to the proximal , thereby transforming the ankle into a functional neo- suitable for prosthetic fitting. The primary purpose of rotationplasty is to achieve limb salvage in scenarios where traditional reconstruction is not feasible, preserving native and joint function to enable enhanced mobility through a below-knee equivalent , which offers greater durability and energy efficiency compared to above-knee alternatives. This approach avoids complications associated with endoprosthetic replacements, such as loosening or infection, while maintaining the patient's own tissues for long-term functionality. Anatomically, the procedure repositions the foot posteriorly through the , allowing the ankle's dorsiflexion and plantarflexion to simulate knee flexion and extension, with the affixed to the using minimal to bridge the resection gap and support prosthetic attachment at the neo-. It is most commonly applied in lower limb reconstruction for pediatric , particularly those requiring extensive resection around the to address malignant tumors.

Patient Selection and Indications

Rotationplasty is primarily indicated for the treatment of malignant tumors such as or located in the distal or proximal , where limb salvage is feasible but traditional reconstruction may not be optimal. It is also recommended for severe congenital femoral deficiency, particularly in cases involving significant limb length discrepancy or functional impairment. Additionally, the procedure serves as a salvage option for traumatic injuries, chronic osteoarticular infections, or non-unions that have not responded to conservative treatments or prior interventions. The procedure is most commonly performed in children and adolescents, typically under 18 years of age, due to their skeletal immaturity, which allows for continued growth and better adaptation to prosthetic fitting post-. In pediatric populations, girls up to approximately age 12 and boys up to age 14 are considered ideal candidates, as their growth potential minimizes the need for repeated revisions compared to endoprosthetic replacements. While less frequent, rotationplasty can be suitable for adults in select cases, such as recurrent tumors or failed limb salvages, provided they demonstrate adequate physical and . Patient selection requires a multidisciplinary focusing on anatomical and functional prerequisites, including preserved integrity, intact popliteal vessels, and full in the and ankle joints to ensure viable and prosthetic use. Psychological readiness of and family is essential, given the cosmetic alterations and long-term prosthetic management involved, with preoperative imaging such as CT scans confirming tumor resectability without or vascular infiltration. Contraindications include inadequate vascular status, poor , high risk, or pre-existing non-ambulatory status, which may necessitate instead. Compared to alternatives like above-knee amputation or endoprosthetic reconstruction, rotationplasty is preferred in very young patients or when prostheses have failed due to or loosening, as it offers superior knee-like motion, improved energy efficiency, and avoidance of pain while reducing the frequency of revisions. This approach is particularly advantageous for maintaining active lifestyles in skeletally immature individuals with femoral sarcomas, where growth-related complications from other methods are a concern.

Historical Development

Early Procedures

The origins of rotationplasty trace back to the early 20th century, amid efforts in to preserve limb function in the face of severe infections and deformities. The procedure was first performed in 1927 by German surgeon Joseph Borggreve on a 12-year-old boy suffering from tuberculous coxitis, a hip infection that had led to a fused and significant limb shortening. Borggreve's motivation was to improve the patient's and overall mobility by salvaging the limb rather than resorting to , reflecting the era's growing emphasis on reconstructive techniques in limb salvage. Borggreve detailed his technique in a 1930 publication, describing a 180-degree rotation of the lower leg to reposition the ankle, which was then fused to the of the to create a functional neo-joint. This innovative approach aimed to convert the ankle into a knee-like , allowing for better prosthetic and . However, the initial case achieved only limited success, as the patient experienced persistent pain and instability, underscoring the challenges of implementing such a complex surgery without modern supportive measures. Prior to the , rotationplasty remained a rare intervention, primarily applied in isolated cases of severe lower limb infections such as , where traditional treatments like or excision failed to restore adequate function. These early applications were rooted in the broader orthopedic advancements of the time, including pioneering work on replacements and corrections during the , though adoption was hampered by the procedure's technical demands. High complication rates plagued these foundational procedures, including , , and vascular issues, exacerbated by inadequate , the absence of effective antibiotics, and rudimentary methods like wires or plates that often failed under stress. Despite these setbacks, Borggreve's work laid the conceptual groundwork for future refinements, demonstrating the potential of rotational in preserving biological tissues for enhanced functionality.

Modern Adoption and Variations

The procedure gained prominence in the mid-20th century through the work of Dutch orthopedic surgeon Cornelis Pieter van Nes, who in 1950 reported successful outcomes from rotationplasty cases, adapting the earlier conceptual approach introduced by Borggreve in the for femoral deficiencies by rotating the and to align with the remaining . Van Nes detailed this modification in a seminal publication in The Journal of Bone and Surgery, emphasizing its utility for congenital short by utilizing the ankle as a functional equivalent in prosthetic fitting. Van Nes reported successful outcomes in multiple cases, establishing it as a viable reconstructive option for proximal femoral deficiencies. Following van Nes's contributions, adoption of rotationplasty expanded significantly after advances in during the 1970s, which improved survival rates for and enabled greater emphasis on limb salvage over . The application of rotationplasty to oncologic resections was pioneered by Salzer et al. in 1981, who popularized it for skeletally immature patients with of the distal femur. This shift facilitated broader application of the technique in tumor management around the , with variations emerging to address diverse anatomical needs, including knee rotationplasty (KRP) for distal femoral resections and tibial turnover procedures for proximal tibial tumors. More recent adaptations for congenital femoral deficiency (CFD) include five innovative techniques developed by in 2021, tailored to the Paley classification system to optimize and fusion for severe cases. Key milestones in the procedure's evolution include a 2007 review in Clinical Orthopaedics and Related Research, which reaffirmed rotationplasty's role in reconstruction by demonstrating effective local control and functional preservation in selected patients. Additionally, a 2019 study on long-term outcomes for patients undergoing rotationplasty reported sustained functional benefits and high patient satisfaction compared to endoprosthetic alternatives, underscoring its enduring value in pediatric .

Surgical Procedure

Preoperative Assessment

The preoperative assessment for rotationplasty is a critical step in evaluating patients, particularly those with or other malignant bone tumors around the , to determine surgical feasibility and optimize outcomes. This process involves a comprehensive evaluation to confirm the absence of contraindications, such as significant dysfunction or inadequate vascular supply, while ensuring the procedure aligns with the patient's overall health and functional goals. A multidisciplinary typically coordinates the assessment, including orthopedic oncologists for tumor management, vascular surgeons to evaluate vessel patency, psychologists or specialists for emotional readiness, and prosthetists to advise on future limb . Rehabilitation physicians, physiotherapists, and nurses may also contribute to , ensuring integrated care from through long-term follow-up. This collaborative approach helps address the complex physical, psychological, and prosthetic needs unique to rotationplasty. Diagnostic imaging plays a central role in delineating tumor extent and ruling out metastasis. Magnetic resonance imaging (MRI) and computed tomography (CT) scans assess soft tissue involvement and bone destruction, while angiography or angio-CT confirms vascular integrity and identifies any encasement requiring reconstruction. Bone scans, such as 99mTc scintigraphy, are used for staging to detect distant metastases, often complemented by chest CT for pulmonary evaluation. Full-length standing radiographs help estimate limb length discrepancies and growth potential in pediatric cases. Functional assessment evaluates the patient's baseline capabilities to predict postoperative adaptation. This includes gait analysis to document pre-existing mobility patterns, testing of ankle range of motion and plantar flexion strength to ensure sufficient function for prosthetic use, and assessment of lower limb innervation and vascularization via tools like the ankle-brachial index. Psychological evaluation focuses on body image acceptance and coping mechanisms, screening for potential distress related to the procedure's cosmetic alterations. Patient education is essential for , involving detailed discussions of cosmetic changes, such as the rotated foot appearing as a "knee" , prosthetic requirements, and expected functional benefits like improved mobility over above- . Multiple consultations, including interactions with prior patients or visual aids, prepare individuals psychologically; for pediatric cases, family counseling addresses long-term implications and support needs to foster acceptance.

Operative Technique

The operative technique for rotationplasty involves a multidisciplinary approach, typically performed by orthopedic oncologists, to resect the affected segment while preserving key neurovascular structures for functional reconstruction. General is administered, and the patient is positioned on a radiolucent to facilitate intraoperative imaging with . The affected limb is prepared and draped free, with posterior and anterior tibial pulses marked preoperatively for continuous monitoring during the procedure. A may be applied to the proximal if deemed appropriate to control bleeding, though its use is optional depending on tumor extent and vascular considerations. The surgical incision is typically a lazy S-shaped cut over the knee joint, beginning proximally and laterally, crossing anteriorly at the joint line, and curving medially and distally to provide wide exposure while minimizing tension on the skin flaps. dissection proceeds meticulously to identify and protect the , which is freed along its course and preserved intact to maintain innervation to the rotated segment. The and vein are similarly safeguarded, with collateral and cruciate ligaments divided after capsulotomy of the knee joint. Muscles are systematically detached: the biceps femoris and pes anserinus laterally and medially, the gastrocnemius heads (with their supply intact), the , and posterior structures such as the semimembranosus and popliteal muscles. The peroneal is identified early and protected. Resection follows oncologic margins, excising the tumor-involved —commonly the distal femoral and , along with the proximal tibial and —using osteotomies approximately 5 mm into healthy if feasible, while ensuring wide margins. Preoperative vessel mapping enables this preservation, allowing safe manipulation without compromising distal . Following resection, the distal segment is externally rotated 180 degrees, positioning the to with the remaining proximal remnant and function as the new . Vascular integrity is confirmed intraoperatively using to detect any compromise, with additional or segmental performed if tension on the is noted. Alignment is adjusted to ensure the foot points posteriorly, optimizing prosthetic fit. Fixation is achieved by arthrodesing the to the , commonly with an intramedullary Rush rod secured by a cross-pin, or alternatively with plates and screws for stability; external fixators may be used in select cases, though cast immobilization is rare. The procedure typically requires 6 to 10 hours, varying with tumor complexity and reconstruction needs. Variations adapt the technique to specific pathologies; for proximal femoral lesions (e.g., types BI or BII per Winkelmann classification), up to three-quarters of the may be resected, potentially involving the and requiring additional osteotomies for pelvic stability. In congenital femoral deficiency, supplementary osteotomies address limb length discrepancies. If vessels are involved, as in revision for infected prostheses, they are transected en bloc and reanastomosed—such as femoral to popliteal or —under microscopic guidance prior to final fixation. Closure is performed in layers: muscles are reapproximated (e.g., rectus femoris to gastrocnemius where applicable), and subcutaneous tissues sutured, and skin closed primarily. Suction drains are placed to prevent formation, and the limb is immobilized in a sterile dressing.

Postoperative Care and Rehabilitation

Immediate Postoperative Management

Following rotationplasty, patients typically remain hospitalized for 4 to 7 days to ensure initial stability and monitor for acute issues. During this period, intravenous antibiotics, such as , are administered prophylactically starting at induction and continuing postoperatively for 48 hours to prevent infection. is managed with a multimodal approach, including continuous epidural analgesia for the first 48 to 72 hours, transitioning to oral opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) as tolerated. The operated limb is immobilized immediately after surgery using a plaster cast or spica cast, often supplemented by internal fixation with plates, screws, or rods, with the initial cast maintained for 6 to 8 weeks and reduced support (e.g., brace) possibly extending protection up to 12 weeks to promote bone healing. Elevation of the limb is standard to minimize swelling, with the cast changed around 2 weeks postoperatively to inspect the surgical site. Venous thromboembolism prophylaxis, such as low-molecular-weight heparin, is routinely provided due to the risk of clotting in the immobilized state. Close monitoring occurs in the for the first 24 to 48 hours, with frequent neurovascular assessments every 1 to 2 hours, including Doppler ultrasound for circulation and checks for signs of or . Nerve function is evaluated daily, and blood tests are performed to assess parameters and inflammatory markers. By day 1 or 2, early begins with bedside exercises, such as active ankle and gentle hip movements within safe limits (e.g., hip flexion under 60 to 80 degrees), progressing to transfers by the end of the first week to prevent secondary complications like .

Rehabilitation Protocol

The rehabilitation protocol for rotationplasty is a phased, multidisciplinary program aimed at progressively restoring mobility, muscle strength, and function following the initial postoperative immobilization, typically lasting 6 to 12 months. This approach emphasizes early intervention to prevent contractures in the rotated limb while building toward functional independence, with therapy sessions occurring 3 to 5 times per week in inpatient or outpatient settings. Phase 1 (weeks 1-6): This initial stage prioritizes , control, and gentle of the neo-knee (formed by the rotated ankle) and , with patients remaining non-weight bearing and using wheelchairs or crutches for transfers. Exercises include isometric contractions of the gluteals and (held for 5-10 seconds, 3 sets of 20 repetitions) and passive for ankle dorsiflexion and plantarflexion to maintain flexibility and promote circulation, performed 2-3 times daily under supervision. Phase 2 (weeks 6-12): As progresses and immobilization is reduced (often after removal around 6-8 weeks), the focus shifts to active-assisted , muscle strengthening, and basic training. Activities involve leg lifts to 30 degrees, weight-shifting exercises on a stable surface (3 sets of 40 repetitions), and parallel bar walking with crutches to develop coordination and balance, advancing from partial to full non-prosthetic support. Phase 3 (3-6 months): Advanced strengthening, , and endurance training dominate, incorporating resisted exercises (e.g., with bands or light weights), single-leg balance drills, and simulated daily activities like to enhance stability and efficiency. Sessions build tolerance for prolonged activity, preparing for higher-level function. A multidisciplinary team coordinates care, with physical therapists leading exercise progression, occupational therapists addressing such as dressing and , and prosthetists consulting from approximately month 2 to align with future device integration. Key milestones include initiation of partial at 6-8 weeks upon radiographic of union, achievement of independent crutch-assisted walking by 3-6 months, and progression to unassisted ambulation by 6 months in most cases. Return to age-appropriate sports or high-impact activities is generally feasible by 1 year, contingent on strength recovery (e.g., muscle grading 5/5). In pediatric patients, who comprise the majority of rotationplasty cases (mean age around 7 years), the protocol incorporates play-based elements—such as games involving balance balls or courses—to improve , compliance, and neurodevelopmental outcomes during all phases.

Prosthetics and Functional Outcomes

Prosthetic Design and Fitting

The for rotationplasty is tailored to leverage the rotated lower leg, where the functions as the new , enabling a below-knee style socket that attaches directly to the residual limb at this site. This socket typically incorporates a flexible inner liner for comfort and an outer shell, often reinforced with lightweight materials, connected to a pylon and an energy-storing prosthetic foot component that facilitates shock absorption and energy return during . The emphasizes body-powered control, with the rotated ankle powering knee flexion and extension through natural muscle activation, while myoelectric options remain rare due to the unique anatomical configuration and reliance on lower leg musculature. Fitting begins with a temporary , often molded preoperatively based on the patient's foot dimensions, to allow early once the incision heals and swelling subsides, typically 4-8 weeks postoperatively. A custom permanent is then fitted around 6-12 months after , with a time of approximately 7-8 months for patients undergoing the procedure for oncologic reasons, enabling most to achieve independent walking. In pediatric cases, which comprise the majority, regular adjustments are necessary to accommodate growth, often requiring socket replacements every 1-2 years to maintain proper alignment and fit. Adaptation to the involves training the patient to utilize the rotary motion of the rotated ankle for prosthetic knee control, with focusing on strengthening the calf muscles to drive flexion and learning compensatory patterns for stability. This process integrates with gait training to optimize energy efficiency, as the design allows the prosthetic foot to mimic natural heel-to-toe progression despite the 180-degree rotation. Innovations in prosthetic design for rotationplasty include the incorporation of lightweight carbon fiber for sockets and pylons, reducing overall weight compared to traditional laminates while enhancing durability and in the foot component. Post-2010s advancements have introduced 3D-printed sockets, enabling precise customization through scanning and , which improves fit for the irregular residual limb shape and shortens fabrication time to days rather than weeks.

Functional Advantages

Rotationplasty offers significant mobility gains by preserving and function in the lower leg, which facilitates a near-normal pattern after rehabilitation. The rotated ankle serves as a functional , allowing for active control and efficient propulsion during ambulation, with studies showing reduced compensatory movements compared to traditional amputations. This preservation enables patients to participate in high-impact activities such as running, , wrestling, and , with reports of individuals returning to competitive sports and even pursuing Paralympic training. Compared to above-knee amputation, rotationplasty demonstrates superior biomechanical efficiency, with a 2025 systematic review and meta-analysis (as of August 2025) indicating approximately 12.5% lower oxygen and cost during walking, leading to improved endurance for daily activities and prolonged ambulation. Additionally, it requires fewer surgical revisions than growing endoprostheses, which often necessitate multiple interventions for lengthening and complication management, providing a more stable long-term reconstruction for skeletally immature patients. The procedure's durability supports active lifestyles in youth, particularly tumor survivors, with a 2007 study reporting excellent functional outcomes, with 85% of patients engaging in sports activities, though with higher energy expenditure compared to age-matched healthy individuals, enabling sustained participation in sports and physical demands over decades. A 2016 report from Johns Hopkins highlighted patients achieving high levels of mobility, including gymnastics and long-distance cycling, underscoring rotationplasty's role in restoring substantial function through optimized prosthetic integration.

Risks, Complications, and Disadvantages

Surgical Risks

Rotationplasty, a complex orthopedic procedure involving the rotation of the lower leg to replace the , carries several immediate perioperative risks inherent to its extensive and vascular manipulation. One of the most critical hazards is vascular , including or ischemia, which can occur due to kinking, poor venous drainage, or failed following vessel rotation or reconstruction. Reported rates of vascular range from 3.7% to 15.4% across studies, with some series documenting up to 12% incidence leading to limb-threatening ischemia or if not addressed promptly. These risks are mitigated through preoperative vascular assessment using arteriography or to evaluate vessel patency and plan the surgical approach, alongside intraoperative monitoring with to maintain distal above 90%. Infection represents another significant perioperative concern, encompassing superficial wound infections or deeper septic complications that can delay healing and necessitate additional interventions. Incidence rates vary, with studies reporting around 4% in primary cases. Prevention strategies include perioperative antibiotic prophylaxis and adherence to sterile techniques, which have been shown to reduce the overall infection burden in major orthopedic surgeries like rotationplasty. Nerve injury, particularly to the sciatic or peroneal nerves, is a rarer but potential intraoperative risk, potentially resulting in or sensory deficits due to or compression during limb and closure. Such injuries occur in less than 5% of cases, with one series noting a 4% incidence of transient sciatic resolved by immediate decompression. Intraoperative monitoring and careful soft tissue handling help minimize this risk. Bleeding and anesthesia-related risks align with those of major orthopedic procedures, including substantial intraoperative blood loss typically ranging from 500 to 1000 due to extensive and osteotomies. Excessive hemorrhage, such as around vascular anastomoses, can exacerbate ischemia and may require transfusion or revision, though standard protocols for and anesthetic management effectively control most cases. Intraoperative specifics, such as during rotation or early fixation failure, pose additional acute threats, though these are infrequent and often linked to underlying quality compromised by tumor or prior treatment. While not quantified in all series, such events can prolong and increase bleeding, underscoring the need for meticulous planning and stable to ensure immediate structural integrity.

Long-term Complications

Bone-related complications in rotationplasty, such as non-union at the fusion site, occur in a minority of cases but can lead to pain, instability, and the need for revision surgery. In a series of 25 patients followed for an average of 5.5 years, one non-union developed 41 months postoperatively and was treated with revision osteosynthesis and bone grafting. Recent studies indicate reoperation rates around 15% linked to persistent issues like bone healing problems. In pediatric patients, where rotationplasty is most commonly performed, ongoing monitoring is essential to address potential leg length discrepancies or angular deformities related to growth. Prosthetic-related challenges arise from the unique rotated , where the foot is positioned posteriorly within the socket, leading to socket irritation and breakdown. The 180-degree compresses soft tissues, increasing pressure points inside the and predisposing patients to chafing, excessive , and abrasions, particularly during prolonged use. Common manifestations include verrucous over the toes due to and poor distal fit, as well as blisters and callosities that limit prosthetic tolerance and require frequent socket modifications. Other long-term issues include sensations, which are notably less prevalent than in traditional above-knee amputations since peripheral nerves remain intact and connected to functional tissues. Additionally, the neo-knee—formed by the rotated ankle joint—experiences biomechanical overload, potentially resulting in degenerative over time. A 2002 study of 22 patients over 10 years documented 21 revisions across eight individuals for various issues, highlighting the cumulative burden of such complications. Similarly, a 2019 analysis of cases reported a 15% reoperation rate linked to persistent long-term problems like joint degeneration. Recent reviews as of 2023 confirm that complication profiles, including vascular and infectious risks, remain consistent, with good long-term function in most patients. Management of these complications emphasizes serial prosthetic adjustments to alleviate socket pressures and prevent skin breakdown, alongside secondary surgeries such as for non-unions or for arthritic changes in the neo-knee. Regular multidisciplinary follow-up, including orthopedic and prosthetist input, is essential to address growth-related concerns in children through timely corrections.

Quality of Life and Psychological Aspects

Physical Quality of Life

Patients undergoing rotationplasty often report physical quality of life metrics comparable to the general population, as assessed by standardized tools like the SF-36 questionnaire. In a 2015 study of 12 patients with a mean follow-up of 14 years, SF-36 physical functioning scores averaged 80.4 ± 15.7, aligning closely with normative values for healthy adults (typically around 84 for this subscale), while role-physical scores were 78.1 ± 24.1, indicating robust daily physical capabilities. A 2019 analysis of eight rotationplasty patients with over 18 years of follow-up similarly found physical health scores on the Rand SF-36 averaging 46.4 (norm-based, where 50 represents the population mean), with overall functioning in line with peers when fitted with appropriate prostheses, supporting sustained physical well-being long-term. Independence in (ADLs) is notably high among rotationplasty recipients, enabling most to manage personal care, mobility, and household tasks without assistance. Studies highlight that patients achieve good functional outcomes in ADLs. Return to and work is common in pediatric and cohorts, reflecting effective reintegration into educational and occupational routines post-rehabilitation. Athletic participation is well-documented, with case evidence showing rotationplasty patients engaging in competitive , including Paralympic-level . Rotationplasty avoids pain and preserves more limb length for better and efficiency. In pediatric cases, rotationplasty accommodates natural growth better than rigid endoprosthetic reconstructions, as the remaining bone continues to elongate with the child, allowing prosthetic adjustments without frequent invasive revisions—unlike megaprostheses, which often necessitate multiple surgeries for lengthening and complication management.

Emotional and Social Impacts

The unusual appearance of the rotated limb, featuring the foot positioned backward to function as a knee joint, frequently presents initial challenges to body image and leads to psychological distress for patients and families following rotationplasty. This cosmetic difference can evoke feelings of self-consciousness, particularly in social and intimate settings, with nearly half of patients in one review reporting impacts on sexuality and interpersonal contact. Comprehensive pre- and post-operative counseling is recommended to address these concerns, helping patients and families process the aesthetic changes and build emotional resilience through education on long-term benefits. Younger patients often demonstrate superior adaptation to alterations compared to older individuals, with a 2002 of 22 long-term survivors reporting psychosocial functioning comparable to the general population, and high overall acceptance of the procedure. Social outcomes post-rotationplasty are generally positive, with minimal disruption to relationships and sustained high , especially among physically active patients. A 2023 study of knee rotationplasty survivors found elevated , emotional , and , independent of , underscoring robust integration. Similarly, a 2021 analysis of rotationplasty for congenital femoral deficiency noted universal patient satisfaction and emotional contentment, despite cosmetic variances, attributing this to early intervention supporting . Research gaps persist regarding long-term in adult rotationplasty patients, as most studies focus on pediatric cohorts with follow-up extending into young adulthood. Data on , particularly in non-Western cultural contexts where aesthetic norms may heighten rejection, remain limited, highlighting the need for broader, diverse investigations.

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