Rotationplasty with vascular reconstruction for prosthetic knee joint infection

Immediate rotationplasty for a severely crushed floating knee in a blast injury: A case report

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.

Simultaneous reconstruction of the bone and vessels for complex femoral defect

Background

Several methods have been reported for intercalary reconstruction of femoral defects. Of these, free vascularized fibula grafts (FVFG) are preferred because of their durability, bone-healing potential, and tolerance to infection. If the bone tumor invades the femoral vessels, simultaneous vascular reconstruction also becomes necessary and significant technical hurdles make limb salvage difficult.

Case presentation

We present a 10-year-old girl who underwent limb-sparing surgery for a distal femur osteosarcoma. The femoral defect was 15 cm long, and the femoral vessel defect was 10 cm long. The femur was reconstructed with bilateral FVFG, and the femoral vessels were reconstructed with saphenous vein grafts. The grafts survived without vascular compromise, and the affected limb was preserved successfully.

Conclusions

Combined use of bilateral FVFG and autologous vein grafts makes limb-sparing surgery for a large osteosarcoma of the femur possible.