Complications and risk factors for failure of rotationplasty: review of 25 patients

Abstract

Rotationplasty is one treatment option for femoral bone sarcomas in skeletally immature patients. This procedure enables patients to avoid phantom pain, limb length discrepancy, or loosening of an endoprosthesis, and good functional outcome has been reported. However, rotationplasty is only rarely indicated and the surgical complications or risk factors for failure of the procedure that might influence choices of treatment or patient counseling have not been well described. We reviewed 25 patients who underwent rotationplasty focusing on risk factors for failure and postoperative complications. Three of 25 patients had vascular compromise resulting in amputation. All three had vascular anastomosis and were resistant to chemotherapy with less than 95% of tumor necrosis. Two of the three patients who underwent amputation had a pathologic fracture before surgery. Late complications included one patient with a tibial fracture, two with wound complications treated with skin grafts, one with nonunion, and one with subsequent slipped capital femoral epiphysis. Rotationplasty was successfully accomplished in 22 of the 25 patients. Patients with large tumors unresponsive to chemotherapy or preoperative pathologic fracture appear at higher risk for failure of rotationplasty presumably as a result of compromise of venous drainage of the leg.

Level of evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Fig. 1A–C

MRI images show an example of a large osteosarcoma of the left distal femur. (A) A T1 coronal image of both femurs shows extensive soft tissue involvement of the left thigh. (B) A sagittal MRI image shows the left femur with contrast. The soft tissue mass is extensive anteriorly and posteriorly and surrounds the femur. (C) An axial T2-weighted MRI image shows the tumor compresses the hamstrings and vascular invasion of the tumor is suspected.

Fig. 2A–C

This graph shows the distribution of each risk factor in the 25 patients. (A) Eighty-four percent of patients received preoperative chemotherapy. (B) Eighty percent of patients underwent vascular anastomosis during the procedure. (C) Sixty percent of patients had pathologic fractures before the surgery.

Fig. 3A–C

The relationship between risk factors and amputation is demonstrated. (A) All amputees showed a poor response to preoperative chemotherapy. (B) All patients with unsuccessful rotationplasty had vascular anastomosis. (C) Two patients with unsuccessful procedures had pathologic fractures before the surgery.