Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors

The objective of this retrospective study was to evaluate the long-term outcome as well as health-related quality of life (HRQL) in patients who underwent rotationplasty for treatment of a malignant bone or soft tissue tumour. At a mean follow-up of 14 ± 9 years. HRQL, assessed by the Short Form Health Survey (SF-36v2) revealed good to excellent scores for each dimension. Interestingly the scores for vitality, social functioning and mental health were significantly higher compared to a representative healthy German sample cohort [21]. Functional long-term outcome measured by the musculoskeletal tumor society score (MSTS) and the Tegner activity level scale also revealed a good functional outcome with 64 ± 12 % and 4.1 ± 0.6 pts., respectively. All but one patient, who was not sure, would choose rotationplasty as therapy option again.

Rotationplasty implies significant shortening of the leg and rotation of the foot 180° around the vertical axis [28]. Therefore the former ankle adopts the role of a neo-knee with ankle dorsiflexion simulating knee flexion [29, 30]. Although the procedure allows for a function more akin to transtibial amputation due to retention of voluntary control of motion at the ‘knee’ level the significant cosmetic alteration implies potential future socio-psychiatric issues that might impact health and HRQL [31]. However, in our cohort we found good to excellent results regarding the subcategory physical health as well as the mental health state. These findings are in line with the work of Veenstra et al. who reported that the subdivisions daily emotional interaction, emotional support in problematic situations and social companionship are comparable to a healthy control group [32]. Consistent with previous studies, the majority of our patients presented well-adjusted in terms of social integration [33]. Though Veenstra et al. also reported almost half of the patients had negative effects of the surgery on initiating social or intimate contact, body image [32]. In this context patients after treatment with mega-prosthesis seem to be more satisfied [32, 34]. At least patients in our study had children following the rotationplasty in four cases.

One of our unexpected findings was, that scores for vitality, social functioning and mental health were significantly higher in our series in comparison to a representative German sample [21]. At first glance this finding is hard to understand. However, in comparing our findings to the results of long-term survivors of other malignancies, our study might underline the concept of posttraumatic growth [35, 36]. In this context Sears et al. reported that 83 % of breast cancer patients felt at least one benefit in their disease [36]. These women mentioned that following cancer diagnosis and consecutive therapy they live now more intensively and consciously. Furthermore, women evaluated the social support they received during the illness as a positive aspect. This seems to be an important aspect of coping with the illness, as it has been demonstrated that social support is a significant predictor for a better long-term quality of life in breast cancer patients [36].

Of course functional outcome has a significant impact of on HRQL, as a significant reduction of HRQL was reported in patients with a MSTS <50 % [37]. In our study only one patient with an MSTS of 47 % was found to be below the 50 % threshold. This patient had sustained an Achilles tendon tear with several consecutive revision surgeries. Our other patients presented with an average MSTS of 64 ± 12.41 %. This is in line with the literature reporting MSTS between 63 and 80 % following rotationplasty [38, 39]. Comparative studies showed significantly higher MSTS-scores after endoprosthetic knee replacement than after rotationplasty [39]. Tunn et al. report MSTS-scores of 77 to 87 % after endoprosthetic limb salvage therapy of primary bone tumors in proximal tibia and distal femur, respectively [40]. However, there are also higher rates of postoperative complications reported following endoprosthetic knee replacement. In this context Warrener et al. noted complications in 42 % of patients following arthroplasty and only in 25 % following rotationplasty [39]. Aseptic loosening and mechanical failure are the most common complications [41]. Additionally, rising numbers of periprosthetic infections with multidrug resistant bacteria cause increasing concern [42]. Our patients were highly satisfied with a stable new joint offering high functionality for daily activities. The nature of the operation obviously causes difficulties with complex movements such as heel walking, jumping or walking on uneven terrain [30, 31]. However, most of our patients reported little problems in participating in sports, one of the patients is even a national champion in handicapped swimming. With an average Tegner activity level scale of 4.1 our patients felt able to perform moderately heavy work and some recreational sports. In comparison a healthy cohort achieved nearly two grades more (5.7) and was therefore able to perform heavy labor, competitive sports and recreational sports several times a week. This seems to be in line with the work of Hillmann et al., who reported that 85 % of the patients following rotationplasty were actively participating in “high-level” sports [43].