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Huynh THN, Kuruvilla DR, Nester MD, Zervoudakis G, Letson GD, Joyce DM, Binitie OT, Lazarides AL. Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives. Curr Oncol Rep 2023; 25:1457-1465. [PMID: 37999825 DOI: 10.1007/s11912-023-01475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques. RECENT FINDINGS The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.
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Affiliation(s)
- Thien Huong N Huynh
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Davis R Kuruvilla
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Matthew D Nester
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | | | | | - David M Joyce
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Odion T Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
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Gulia A, Prajapati A, Gupta S, Exner U, Puri A. Rotationplasty after failed limb salvage: an alternative to amputation. Eur J Orthop Surg Traumatol 2022:10.1007/s00590-022-03333-9. [PMID: 35864216 DOI: 10.1007/s00590-022-03333-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Limb salvage procedures for musculoskeletal tumors have inherent complications. Though most complications can be managed with retention of the reconstructions, occasionally salvaging these reconstructions is not possible. We evaluated the outcomes of patients undergoing rotationplasty after multiple failed revisions of limb salvage surgery and document the success rate of this "salvage" technique and the subsequent functional outcome of these patients. METHOD Between January 1, 1999, and December 31, 2018, 14 patients (12 male and 2 female) with a median age of 24 years (11-51 years) underwent rotationplasty after multiple failed revisions of limb salvage surgery. Indication for rotationplasty was infection (10 patients), failed megaprosthesis (2 patients), unstable biological reconstruction (1 patient) and local recurrence (1 patient). The mean number of surgeries done before the patient underwent rotationplasty was 5 (range 2-7). RESULTS One patient developed a vascular complication (venous congestion) immediately after rotationplasty and underwent an early amputation. The remaining 13 patients had no surgical complications. Mean Musculo Skeletal Tumor Society score in 13 evaluable patients was 26 (23-30). CONCLUSION Our study demonstrates the utility of rotationplasty as a "salvage" procedure after multiple failed lower limb salvage surgeries. It offers good success rates, low rates of complications and good functional outcomes in carefully selected cases.
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Affiliation(s)
- Ashish Gulia
- Bone and Soft Tissue Services, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, India.
| | - Ashwin Prajapati
- Bone and Soft Tissue Services, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Srinath Gupta
- Bone and Soft Tissue Services, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Ulrich Exner
- FMH Orthopädische Chirurgie Und Traumatologie, Orthopaedie Zentrum Zuerich Ozz, 8038, Zurich, Germany
| | - Ajay Puri
- Bone and Soft Tissue Services, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, India
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Lu CK, Liu YC, Chen CT, Fu YC, Liu WC. Immediate rotationplasty for a severely crushed floating knee in a blast injury: A case report. Trauma Case Rep 2022; 37:100600. [PMID: 35028358 PMCID: PMC8741605 DOI: 10.1016/j.tcr.2021.100600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 11/23/2022] Open
Abstract
Rotationplasty is a durable biological reconstruction strategy that is most often performed in children with osteosarcoma of the distal femur. This limb-sparing procedure essentially employs a 180° “rotation” of the distal limb followed by fixation to the proximal limb, resulting in superior functionality and flexibility as compared to those of alternative surgeries. However, despite the many advantages of rotationplasty, literature regarding its indications, techniques, and outcomes in adult patients is scarce. A 37-year-old man presented with a severely floating knee in a blast injury. In addition to femoral shaft fracture, the proximal tibia was comminuted severely from the articular surface to the diaphysis, and the soft tissue was equally crushed. Because his ankle was relatively intact, immediate rotationplasty was performed for joint reconstruction combined with anastomosis of the neurovascular bundles. He underwent another bone grafting surgery 8 months after the initial surgery to improve bone union and subsequently began full weight-bearing with a prosthesis 3 months later. After more than 4 years of follow-up, he could walk without assistance, was satisfied with his overall recovery, and had a decent range of motion. However, due to the injured tibial nerve from the initial accident, he continued to experience numbness of the left foot, which prevented him from wearing the prosthesis for more than 3 h at a time. Based on our experience and literature review, opting for rotationplasty after a trauma will provide optimal outcome for the patient only when the following conditions are met: (1) healthy and active preoperative status, (2) integrity of the nerves, (3) competence of the prosthetic team, and (4) access to an emergency microsurgical reconstruction trauma center facility.
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Affiliation(s)
- Chun-Kuan Lu
- Department of Orthopedic Surgery, Park One International Hospital, Kaohsiung, Taiwan
| | - Ying-Chun Liu
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Ting Chen
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yin-Chih Fu
- Department of Orthopedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Orthopedic Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Wen-Chih Liu
- Department of Orthopedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Ph.D Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Mahmoud A, Aboujaib MF, Meda MR. Long-term follow-up of patients with rotationplasty. Int J Surg Case Rep 2021; 79:295-298. [PMID: 33508611 PMCID: PMC7840439 DOI: 10.1016/j.ijscr.2021.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 11/05/2022] Open
Abstract
Rotationplasty creates a neo-knee joint that acts similarly to the knee joint. Young patients’ limb-salvage procedures should insist on nearly full return to high activity daily life activities. Rotationplasty is considered a reasonable indication in patients with low-income status.
Introduction and importance Rotationplasty considered a limb-salvage procedure and has a lot of advantages when comparing it with endoprostheses or above-knee amputation. Case presentation We report two cases of young patients with osteosarcoma with rotationplasty being performed for both of them. Clinical discussion Patients with rotationplasty have less restrictions in daily life activities due to pain comparing with patients with endoprostheses. Conclusion Our aim here is to confirm that rotationplasty is an applicable, successful and alternative procedure to endoprostheses or above-knee amputation, when doing it based on an accurate indication and patients regain their previous daily life activities and satisfaction.
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Affiliation(s)
- Ali Mahmoud
- Department of Orthopedic Surgery, Damascus University, Damascus, Syria; Albairouni University Hospital, Damascus, Syria(1)
| | - Muhammed Fayez Aboujaib
- Department of Orthopedic Surgery, Damascus University, Damascus, Syria; Albairouni University Hospital, Damascus, Syria(1).
| | - Muhammad Rafat Meda
- Department of Orthopedic Surgery, Damascus University, Damascus, Syria; Albairouni University Hospital, Damascus, Syria(1)
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Puetzler J, Deventer N, Gosheger G, Goesling T, Winkelmann W, Budny T. Hip transposition procedure due to osteosarcoma metastasis of the ilium in a patient with preexisting rotationplasty leads to satisfactory functional result: A case report. Int J Surg Case Rep 2020; 77:739-742. [PMID: 33395886 PMCID: PMC7718121 DOI: 10.1016/j.ijscr.2020.11.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 12/02/2022] Open
Abstract
Hemipelvectomy (PI-II) after rotationplasty on the same leg resulted in a good functional result in a 16 year old male patient with osteosarcoma. For hemipelvectomy, the musculus gluteus maximus is essential for soft tissue coverage, therefore supplying structures must be preserved. The triradiate cartilage of the acetabulum closes around a bone age of 12 years in boys and then is no sufficient barrier for an osteosarcoma.
Introduction The hip transposition is a limb salvage procedure for periacetabular malignancies. Here we present the case of a patient that already had a preexisting ipsilateral rotationplasty. Presentation of case A 16 year old male patient with an Osteosarcoma of the left distal femur was treated with wide surgical resection of the tumor and rotationplasty (Salzer/Winkelmann type A1). Despite adjuvant chemotherapy (EURAMOS protocol) he was diagnosed with metachronous metastases in the lung and in the left ilium affecting the acetabulum. As a limb salvage procedure the patient received an internal hemipelvectomy Enneking PI-II and an attachment of the femoral head with a Trevira tube to the sacrum using suture anchors. After six weeks a prosthesis was fitted and gradually full weight bearing was allowed. The patient achieved a good functional result as he was able to walk freely for three more years before he passed away. Discussion The hip transposition procedure does not require the implantation of a large tumor prosthesis and thus avoids the problem of an increased risk of infection. Even with preexisting ipsilateral rotationplasty a good functional outcome that allowed the patient full weight bearing could be achieved. Conclusion If there are already existing deformities, such as rotationplasty on the same leg, the hip transposition procedure can be considered for periacetabular malignancies, as it can achieve satisfactory results.
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Affiliation(s)
- Jan Puetzler
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany.
| | - Niklas Deventer
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Georg Gosheger
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Thomas Goesling
- Department of Trauma- and Orthopaedic Surgery, Städtisches Klinikum Braunschweig, Germany
| | - Winfried Winkelmann
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Tymoteusz Budny
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
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Elía Martínez JM, Puerta de Diego R, Gallart Úbeda V, Elía Martínez I. [ Rotationplasty in a schoolboy for osteosarcoma: Prosthesis fitting and update]. Rehabilitacion (Madr) 2020; 55:228-232. [PMID: 33183793 DOI: 10.1016/j.rh.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/07/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The classical treatment of osteosarcoma used to be ablative surgery. After the appearance of adjuvant chemotherapy, survival in these patients increased, and with it, the number of affected school age children with high growth potential. Hence, reconstructive surgeries are currently proposed instead of conventional bone resections due to greater limb preservation and better functional status than those achieved with conventional amputations. CASE PRESENTATION We describe a case of osteosarcoma in a 9-year-old boy with a history of retinoblastoma. The tumour involved the entire length of the left femur. He also had a lung metastasis. Given the incomplete response to neoadjuvant chemotherapy, we chose bone resection, rotation and fitting of the left lower limb and thoracoscopy to treat the lung injury. A bypass ortoprosthesis was placed for the first 6 weeks, until there was healing, bone consolidation and absence of complications, followed by a definitive orthoprosthesis for the next 4 months. At one year, the patient was able to walk independently with the use of the ortoprosthesis, swimming with a fin adapted to the stump and was had restarted cycling. At the last clinical review, at the age of 13 years, he is disease free and continues to have periodic follow-up visits in our office for adaptations to the prosthesis according to his growth. DISCUSSION This case highlights the various reconstructive options available and the difficulties encountered in the management of these aggressive malignant processes. Rotationplasty is a viable therapeutic option in young patients with osteosarcoma, which allows the child to participate again in premorbid daily and recreational activities.
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Affiliation(s)
- J M Elía Martínez
- Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - R Puerta de Diego
- Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - V Gallart Úbeda
- Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - I Elía Martínez
- Consorcio Hospital General Universitario de Valencia, Valencia, España
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Zhao X, Liu Y, Li J, Bi J, Xu M. [Application of rotationplasty in treatment of osteosarcoma of distal femur in children]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2020; 34:1215-1220. [PMID: 33063482 DOI: 10.7507/1002-1892.202003083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of rotationplasty in treating osteosarcoma of distal femur in children. Methods A clinical data of 10 children with osteosarcoma of distal femur treated with rotationplasty between March 2014 and June 2016 was retrospectively analyzed. There were 7 boys and 3 girls with an average age of 6.7 years (range, 4-10 years). There were 4 cases of osteoblastic osteosarcoma, 4 cases of mixed osteosarcoma, and 2 cases of chondroblastic osteosarcoma. All children were staged as Enneking stage ⅡB. The disease duration ranged from 3.5 to 6.0 months (mean, 4.6 months). The lower limb functional scoring system of 1993 Musculoskeletal Tumor Society (MSTS93), Toronto Extremity Salvage Score (TESS), and knee mobility were used to evaluate postoperative function. Tumor recurrence and metastases were monitored by radiograph. Results Poor superficial incision healing occurred in 1 patient, and healed after dressing change. The other incisions healed by first intention. All children were followed up 24-72 months (mean, 52.6 months). No local recurrence was observed during follow-up. Three of the ten patients suffered from metastases including 1 dying of multiple organ dysfunction syndrome, 1 alive with tumor, and 1 tumor free survival. Painful callosities and ulcers which related to prosthetic wear occurred in 2 patients and turned up after optimizing prosthetic fit and physiotherapy. The fracture healing time was 2.5-5.0 months (mean, 3.5 months). All children could walk independently at 4 months postoperatively. At last follow-up, the MSTS93 score was 19-25 (mean, 22) and the TESS score was 87-93 (mean, 90). The extension of knee joint mobility with artificial limbs was 0°-10° (mean, 5°), and the flexion of knee joint mobility with artificial limbs was 85°-95° (mean, 90.5°). Conclusion Rotationplasty in treating osteosarcoma of distal femur in children with limb salvage difficulties can effectively preserve the limb function and improve the quality of life, and it can be used as an alternative to amputation.
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Affiliation(s)
- Xuelin Zhao
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Yatao Liu
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Jianxiong Li
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Jingyou Bi
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Meng Xu
- Department of Orthopedics, the First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R.China
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Grimsrud C, Killen C, Murphy M, Wang H, McGarry S. Long-Term Outcomes of Rotationplasty patients in the treatment of lower extremity sarcomas with cost analysis. J Clin Orthop Trauma 2020; 11:S149-S152. [PMID: 31992936 PMCID: PMC6977185 DOI: 10.1016/j.jcot.2019.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE There are many options for restoration of function in treating lower extremity sarcomas in young children. The trend has moved towards the use of expandable prosthetics for treatment; however, this has been fraught with complications and expense. The aim of this study was to assess long-term functional outcome scores and emotional satisfaction of rotationplasty and megaprosthesis patients compared to the general population. METHODS Surveys querying surviving members of a rotationplasty cohort from our institution were sent out including MSTS, TESS and Rand SF-36 questionnaires. Demographic information, surgical intervention, disease status and length of follow-up were collected. RESULTS The average MSTS score of the eight respondents available and who agreed to participate in the study was 65.4%. The average TESS was 90.0%. The results of our eight respondents showed Rand SF-36 results with norm-based scoring averages of 46.4 for physical health and 55.6 for mental health. In this study, the patients who were alive with no evidence of disease averaged greater than eighteen-years of follow-up. CONCLUSION Patients functioned well relative to their peers when in an appropriate prosthesis. Patients were emotionally satisfied with rotationplasty and functioned in-line with the general population physically and mentally.
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Affiliation(s)
- Courtney Grimsrud
- University of Nebraska Medical Center, Department of Orthopaedic Surgery & Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE, 68198-5640, USA
| | - Cameron Killen
- Loyola University Chicago, Department of Orthopaedic Surgery and Rehabilitation (Academic Office), Maguire Center, Suite 1700, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Michael Murphy
- Loyola University Chicago, Department of Orthopaedic Surgery and Rehabilitation (Academic Office), Maguire Center, Suite 1700, 2160 South First Avenue, Maywood, IL, 60153, USA,Corresponding author.
| | - Hongmei Wang
- University of Nebraska Medical Center, College of Public Health, 984350 Nebraska Medical Center, Omaha, NE, 68198-4350, USA
| | - Sean McGarry
- University of Nebraska Medical Center, Department of Orthopaedic Surgery & Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE, 68198-5640, USA
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Abstract
BACKGROUND AND AIM Rotationplasty is an important and demanding challenge for physiotherapists. The aim of this paper is to describe the functional outcome achieved by a patient undergoing rotationplasty in adult age following osteosarcoma. Case description and Methods: The patient was followed throughout the rehabilitation course and the results achieved were recorded at 6, 9 and 12 months after surgery. Findings and outcomes: The results progressively improved in terms of function, functional performance and quality of life. The MSTS and TESS scales showed an improvement respectively of 20 and 23 percentage points, reaching levels of 80% and 87%. The quality of life perceived by the patient increased in the three assessments, the mental health score at one-year follow-up is higher than that expected for the population. CONCLUSIONS Rotationplasty, even in adult age, produces good results and in the treatment of tumours in adults this operation should be taken into consideration. Clinical relevance Rotationplasty in adult age following osteosarcoma combined with a rehabilitation program enabled a patient to reach a successful outcome in terms of functional performance and quality of life.
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Abstract
PURPOSE Amputations and fitting surgery have a long history in children with limb deficiencies. With the current developments in limb reconstruction and new techniques in prosthetics, the indications for amputation and fitting surgery might have shifted, but still have a very important role in creating high functional performance, optimal participation and quality of life. The purpose of this current concepts article is to give an overview of the indications, dilemmas and technical considerations in the decision-making for amputation and fitting surgery. A special part of this overview is dedicated to the indications, variations and outcomes in rotationplasties. METHODS The article is based on the experience of a multidisciplinary reconstruction team for children with complex limb deficiencies, as well as research of the literature on the various aspects that cover this multidisciplinary topic. RESULTS For those children with a more severe limb deficiency, reconstruction is not always feasible for every patient. In those cases, amputation with prosthetic fitting can lead to a good result. Outcomes in quality of life and function do not significantly differ from the children that had reconstruction. For children with a postaxial deficiency with a femur that is too short for lengthening, and with a stable ankle and foot with good function, rotationplasty offers the best functional outcome. However, the decision-making between the different options will depend on different individual factors. CONCLUSIONS Amputations and rotationplasties combined with optimal prosthesis fitting in children with more severe limb deficiencies may lead to excellent short- and long-term results. An experienced multidisciplinary team for children with complex limb deficiencies should guide the patient and parents in the decision-making between the different options without or with prosthesis.
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Affiliation(s)
- Ralph Sakkers
- Department of Orthopaedic Surgery, Wilhelmina Children’s Hospital, University Medical Center Utrecht, P.O. Box 85090, 3508 AB Utrecht, The Netherlands
| | - Iris van Wijk
- Brain Centre Rudolf Magnus and Centre of Excellence for Rehabilitation Medicine, De Hoogstraat Rehabilitation, University Medical Center Utrecht, Utrecht, The Netherlands
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