Is Rotationplasty Still a Reasonable Reconstruction Option for Patients With a Femoral Bone Sarcoma? A Comparative Study of Patients With a Minimum of 20 Years of Follow-up After Rotationplasty and Lower Extremity Amputation.
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BACKGROUND: Rotationplasty was first introduced as an alternative to above-the-knee amputation after resection of bone sarcomas of the distal femur by Salzer in 1974. Although the procedure involves a substantial body image issue, it has many advantages such as durability of the reconstruction (compared with limb salvage procedures) and avoidance of phantom pain (compared with amputation). Although several reports have shown intermediate outcomes of rotationplasty, very long-term results in terms of function, activity levels, and quality of life (QoL) in comparison with above-the-knee amputation have not been reported. This work aims to fill this gap left by prior reports. QUESTIONS/PURPOSES: (1) Is there a difference in revision-free survival in very long-term follow-up after rotationplasty and transfemoral amputation or knee disarticulation? (2) Are patient activity levels after rotationplasty comparable with those after transfemoral amputation or knee disarticulation in the very long term? (3) Do activity levels differ in terms of QoL? (4) Within the group of patients who have undergone rotationplasty, is the ROM in the neo-knee associated with QoL 20 to 40 years later? METHODS: Between 1961 and 1995, a total of 360 patients were treated for bone and soft tissue sarcoma of the lower extremity. Fifty-four patients were treated with A1 rotationplasty, 124 were treated with an amputation, and 182 were treated with a limb salvage procedure. Of those who underwent amputation or rotationplasty, 9% (11 of 124) and 15% (8 of 54), respectively, were lost to follow-up before a period of 20 years without meeting a study endpoint, and another 71% (88 of 124) and 44% (24 of 54), respectively, died prior to 20 years with intact residual limbs, leaving 20% (25 of 124) and 41% (22 of 54), respectively, of the original group who had a follow-up time of at least 20 years. Four patients with amputations declined to participate in the study, while three patients with transtibial amputations and one patient with a complete language barrier after rotationplasty were excluded. These 39 patients with a minimum follow-up time of 20 years (mean [range] 36 years [23 to 55]) were available and gave their consent to this retrospective comparative study at the local orthopaedic department. The decision between rotationplasty and endoprosthetic replacement was made after thorough consultation and according to the patient's choice. As general guidance, Salzer's idea was to provide rotationplasty to patients who had a strong desire for higher levels of activity. Endoprosthetic reconstructions were more likely indicated given a patient's preference for a cosmetically uncompromised limb. Amputation was primarily performed one decade before the availability of rotationplasty and was mostly an alternative to rotationplasty because of patient refusal or surgical limitations. Therefore, the two groups differed in age at follow-up; however, they did not differ in age at surgery, BMI, gender ratio, tumor entities, or tumor localization. All-cause revisions presented in Kaplan-Meier curves, pain sensation, and functional and QoL outcomes, such as ROM, University of California Los Angeles (UCLA) activity scores, 5-level EuroQol 5-domain (EQ-5D-5L) scores, and 36-Item Short Form survey scores, were assessed. RESULTS: There was no difference between patients after rotationplasty and amputation in terms of survivorship free from revision of unpredictable events at 20 years (86% [95% confidence interval (CI) 85% to 95%] versus 67% [95% CI 64% to 94%]; p = 0.27). There was no difference in median UCLA activity scores between the groups (rotationplasty 6 versus amputation 5; p = 0.18). Patients treated with a rotationplasty had less pain than those treated with amputation (EQ-5D-5L pain/discomfort, p < 0.01). The EuroQol (EQ) index was higher in patients who had rotationplasty in comparison with patients who underwent amputation (0.92 versus 0.81; p = 0.01). A linear regression model that controlled for length of follow-up, gender, age, and type of surgery found that having rotationplasty was associated with a better EQ index than undergoing amputation (R = 0.538, R 2 corrected = 0.212; p = 0.011). There were positive correlations between the EQ index and both flexion (ρ = 0.53 [95% CI 0.03 to 0.82]; p = 0.03) and ROM (ρ = 0.54 [95% CI 0.05 to 0.82]; p = 0.03) in the neo-knee. CONCLUSION: After rotationplasty and amputation, patients show similarities at long-term follow-up in the use of external prostheses and in cosmetic issues after limb loss. Both groups might have benefitted from the advancements in prosthetics that have occurred and will continue to do so; however, in this study, patients seem to have better QoL after rotationplasty compared with those with amputation. This study intentionally did not compare outcomes after an extendible or modular endoprosthesis with outcomes after rotationplasty. However, failures after endoprosthetic reconstructions occur frequently in the long term, whereas they rarely exist after rotationplasty. The use of rotationplasty, therefore, might be a benefit not only to individual patients but also to stakeholders in healthcare systems. Furthermore, this study emphasizes the benefit of rotationplasty as a durable surgical method that enables patients for high physical performance. Therefore, tumor centers around the world should be aware of these benefits, and patients must be given the opportunity to receive information about it. Currently, rotationplasty might be beneficial in certain situations, at least when patients and/or parents accept this kind of reconstruction. Children younger than 5 to 7 years and small in height, patients considered for megaprostheses with borderline or insufficient soft tissue coverage, and even patients who are highly active and feel that sporting activities are most important for their lifestyle are potential candidates for rotationplasty. Furthermore, rotationplasty might be an option after failed limb salvage surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.