Modified Borggreve-Van Nes-Winkelmann rotationplasty for surgery in developing countries

Abstract

Background: Amputation is still the most common therapy for patients suffering from osteosarcoma in Myanmar, despite the fact that limb salvage surgery e.g. Borggreve-Van Nes-Winkelmann rotationplasty for malignant tumors located within the distal femur or proximal tibia is the current state-of-the-art reconstructive procedure. A safe and reliable operation technique is crucial in order to perform a complex surgical procedure like the rotationplasty in lower-middle income economies with limited infrastructure and resources. The authors present seven cases of patients with osteosarcomas that received a Borggreve-Van Nes-Winkelmann rotationplasty with an evaluation of the procedures focusing on safety and sustainability.

Methods: From 2019 until 2020, seven young patients with osteosarcomas of the distal femur or proximal tibia were treated with Borggreve-Van Nes-Winkelmann rotationplasties in the Orthopaedic Hospital in Mandalay, Myanmar. As modification of the standard procedure the dissection and subsequent clamping of the femoral artery in order to minimize blood loss as well as the formation of an adipocutaneous flap that minimizes swelling and decreases the pressure on the vessels were successfully performed. This modified procedure resembles a safe and simplified surgical technique that is feasible under the circumstances of lower-middle income economies with good outcomes.

Results: All patients showed good functional and aesthetic results. One of the seven patients needed secondary wound closure due to wound dehiscence.

Conclusions: A simplified and safe operation technique for the performance of the Van Nes-Borggreve rotationplasty was adapted to the given constraints in lower-middle income economies and proved to be successful. Trial registration All patients approved to participate in the study and have given consent to publication.

Keywords: Orthopedic surgery; Plastic surgery; Reconstructive surgical procedure; Surgical oncology.

Fig. 1

Clinical images and X-rays of patients 1–3. a and b Patient 1 with osteosarcoma of the left distal femur and corresponding X-ray; c and d Patient 2 with osteosarcoma of the right distal femur and corresponding X-ray; e and f Patient 3 with osteosarcoma of the left distal femur and corresponding X-ray

Fig. 2

Clinical images and X-rays of patients 4–7. a and b Patient 4 with osteosarcoma of the left distal femur and corresponding X-ray; c and d Patient 5 with osteosarcoma of the left proximal tibia and corresponding X-ray; e and f Patient 6 with osteosarcoma of the right proximal tibia and corresponding X-ray; g and h Patient 7 with osteosarcoma of the distal femur and corresponding X-ray

Fig. 3

a First incision on the proximal medial thigh to expose the femoral artery and vein. b Continuous exposure of the blood vessels

Fig. 4

Clamping of the femoral artery and vein after dissection on proximal medial thigh region

Fig. 5

Adipo-cutaneous flap. Dissection of the circular adipo-cutaneous flap is depicted. Tissue thickness was assured to provide an optimal coverage of the osteosynthesis

Fig. 6

Surgical dissection of the sciatic nerve with the transition into the tibial nerve and the common peroneal nerve proximal of the popliteal fossa

Fig. 7

Exposure of the popliteal anatomical structures. a Dissection of popliteal lymph nodes for biopsy and b dissection of popliteal artery and vein

Fig. 8

Tumor resection. a The resected tumor mass is shown. b The neurovascular structures including the popliteal vessels and the sciatic nerve were preserved

Fig. 9

Bony reconstruction. Intraoperative image of osteosynthesis of tibia and femur with a dynamic compression plate is shown

Fig. 10

Vascular repair. End-to-end anastomoses of the femoral and the popliteal artery and vein were performed

Fig. 11

Postoperative results. A postoperative image of the reconstructed limb after osteosarcoma of the distal femur is depicted