Vascular management in rotationplasty

Abstract

The Van Nes rotationplasty is a useful limb-preserving procedure for skeletally immature patients with distal femoral or proximal tibial malignancy. The vascular supply to the lower limb either must be maintained and rotated or transected and reanastomosed. We asked whether there would be any difference in the ankle brachial index or complication rate for the two methods of vascular management. Vessels were resected with the tumor in seven patients and preserved and rotated in nine patients. One amputation occurred in the group in which the vessels were preserved. Four patients died secondary to metastatic disease diagnosed preoperatively. The most recent ankle brachial indices were 0.96 and 0.82 for the posterior tibial and dorsalis pedis arteries, respectively, in the reconstructed group. The ankle brachial indices were 0.98 and 0.96 for the posterior tibial and dorsalis pedis arteries, respectively, in the rotated group. Outcomes appear similar using both methods of vascular management and one should not hesitate to perform an en bloc resection when there is a question of vascular involvement.

Fig. 1

The initial portion of the operation concerns dissection and mobilization of the sciatic nerve. The nerve is localized by isolating the common peroneal nerve and dissecting proximally.

Fig. 2

Vascular shunts are used to maintain perfusion of the distal extremity during resection of the mass. After the resection is completed, the respective artery and vein are repaired by end-to-end anastomoses.

Fig. 3

A pulse oximeter is used on the distal portion of the ipsilateral extremity throughout the entire procedure with maintenance of oxygen saturation greater than 90%.

Fig. 4A–C

A patient is shown 57 months after rotationplasty (A) wearing his prosthesis, (B) sitting and (C) standing without his prosthesis. He is clinically and radiographically free of disease. His wound healed with no skin loss and his prosthesis is well fitting and highly functional. He is extremely active and enjoys inline skating and bicycle riding (Videos 1 and 2, Supplemental Website Materials; supplemental materials are available with the online version of CORR).