What Are the Surgical Complications Associated With Oncologic Rotationplasty Procedures? A Systematic Review

In the surgical treatment of lower extremity sarcomas, rotationplasty provides a durable biologic reconstruction option. It effectively allows the patient to function with a transtibial amputation, without the burden of a nonbiologically based reconstruction. Despite robust function and durability, rotationplasty may invite its own array of complications. A thorough description of rotationplasty complications and outcomes is lacking in published reports, limiting effective patient and family counseling. Moreover, improving awareness of the potential complications will allow surgeons the opportunity to mitigate their risk of occurrence or detect them early in order to minimize their downstream consequences.

(1) What are the modes of complication and the proportion at which they occur after oncologic rotationplasty surgery? (2) What is the timing of these complications relative to the index surgical procedure? (3) What proportion of patients ultimately undergo conversion to an amputation, and when, relative to the index rotationplasty, does conversion occur?

We performed a review through the PubMed and Scopus databases for rotationplasty procedures for oncologic indications between 1948 and November of 2024 (both last searched November 15, 2024). This yielded 293 articles; 117 were excluded because they did not include the rotationplasty procedure. We then excluded 15 studies for a nononcologic indication for surgery, 101 studies with cohorts of < 10 patients, 14 for inadequate reporting of postoperative complications, and 20 for duplication of published data by the same study group. We included manuscripts if they had an oncologic indication for the procedure, a lower extremity procedure, a cohort of > 10 patients, and clear reporting of postoperative complications. Ultimately, 26 articles were included in this review. Two different authors screened and extracted clinical metrics, which they recorded in a spreadsheet for collation and evaluation. Risk of bias and methodological quality of the included studies was quantitatively assessed via two methods: the Newcastle-Ottawa Scale (NOS) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Overall risk of bias and methodological quality of the included studies was moderate to poor. Data were pooled for ease of comprehension, but we did not perform a formal meta-analysis of the data. In the papers that reported gender, most patients were boys or men (65% [321 of 491]). The age at time of surgery ranged from 3 to 64 years. Osteosarcoma was the most common diagnosis, accounting for 71% (527 of 746) of diagnoses, and the distal femur was the most common location (56% [419 of 746]). Regarding surgical techniques, for those with reported data concerning vascular management, 65% (309 of 476) utilized an anastomosis construct, whereas 35% (167 of 476) underwent a loop procedure. For osteosynthesis, most reported data demonstrated use of a plate and screw construct (92% [327 of 354]) rather than an intramedullary nail (3% [10 of 354]).

There were 746 patients in the included 26 articles, 34% (254) of whom were reported to have had a complication. Twenty-seven patients within our cohort were reported to have had multiple complications, so the total number of reported complications was 281. The most common complications involved the osseous construct (11% [81 of 746]), followed by the vascular system (8% [59 of 746]), then wound healing (7% [55 of 746]). Other less commonly reported complications were neurologic injuries (5% [35 of 746]) and infection (4% [31 of 746]). With regard to timing of postoperative complications, 75% (36 of 48) of osseous construct-related issues arose within the first year, and 94% (31 of 33) of vascular complications occurred within 14 days of surgery. Details of surgical complications were not adequately reported in many series within our cohort.

Our review suggests that 34% of all patients with rotationplasty experienced a postoperative complication, the most common being osseous construct-related, followed by vascular and soft tissue complications. These data suggest that rotationplasty is a robust, durable reconstruction option for patients undergoing surgery for a lower extremity bone sarcoma. It carries small yet serious early complication risks; however, this dramatically tapers after osteosynthesis is achieved. A prospective review of multi-institutional perioperative data would allow for a more comprehensive and comparative summary of these procedures to investigate the surgical factors that influence the occurrence of complications and reoperation.

Level IV, therapeutic study.