A thirty-one-year-old healthy male laborer sustained bilateral injury of the lower extremity as a passenger in a train accident. After a two-hour extrication, the patient was intubated and resuscitated with intravenous administration of fluids at the site of the accident. He was then transported to the Trauma Department of the Hannover Medical School. On arrival 3.5 hours after the injury, physical examination and radiographs revealed a grade-IIIC open8, AO type-33 C3.316 fracture of the distal portion of the left femur (Fig. 1-A); no pulse in the left foot; and a closed fracture of the right tibial shaft. The mangled extremity severity score for the left lower limb was 9 points (4 points for a massive crush injury; 1 point for transient hypotension that responded to fluid resuscitation; 3 points for a limb that had no pulse, was cool, and had no capillary refill; and 1 point for an age between thirty and fifty years)10. There were no head or thoraco-abdominal injuries.
The patient was taken immediately to the operating room, without preoperative angiography. After débridement and irrigation of the wound, specimens were taken for culture and intravenous antibiotic therapy (two grams of cefazolin three times a day) was begun. The sciatic nerve was examined and found to be intact. A nineteen-centimeter-long segment of bone was non-viable or missing. A seven-centimeter-long segment of damaged superficial femoral artery was removed, the distal part of the femur was shortened nineteen centimeters, and an end-to-end anastomosis of the artery was accomplished. The femoral vein was not injured and needed no repair. Skeletal stabilization was performed with a condylar buttress plate, and a half-pin uniplanar anterior external fixator (Effner-Biomet, Berlin, Germany) was used with two pins in the femur and two pins in the tibia to span the knee joint temporarily. Because of intra-articular loss of bone, only partial reduction of the distal articular surface of the femur could be accomplished. A four-compartment fasciotomy was performed in the leg. The contralateral leg was treated with tibial nailing without reaming and a four-compartment fasciotomy.
The wound was debrided every two or three days. Despite continuous intravenous administration of antibiotics (initially two grams of cefazolin three times a day for eight days, followed by four grams of piperacillin and 200 milligrams of tobramycin twice a day for four days, then 300 milligrams of ofloxacin three times a day and 200 milligrams of tobramycin twice a day for ten days, and finally two grams of ampicillin three times a day and 160 milligrams of gentamicin twice a day for ten days), cultures of specimens taken from the wound during the procedures showed polymicrobial infection with coagulase-negative Staphylococcus, non-hemolytic Streptococcus, and Enterococcus. Closure of the wound, with use of local tissues made available by the amount of skeletal shortening, was accomplished gradually over two weeks.
Three weeks after the injury, the external fixator was removed from the left lower limb (Fig. 1-B). The motor and sensory functions of the leg, ankle, and foot were normal, except for mild peroneal weakness (manual testing revealed a motor strength of 3 of 5 for dorsiflexion of the ankle). Despite treatment with appropriate antibiotics and a total of ten débridement procedures, there was persistent drainage and Enterococcus, Staphylococcus, non-hemolytic Streptococcus, Proteus, Bacillus cereus, and Acinetobacter baumanii were grown on culture. Three months after the injury, it was decided that the infection could not be eradicated and the distal part of the femur could not be salvaged.
Therapeutic options, which were reviewed with the patient, included above-the-knee amputation, arthrodesis of the knee with shortening and subsequent Syme amputation, arthrodesis of the knee with staged limb-lengthening, and shortening followed by rotationplasty. After watching a video demonstration and speaking with a patient who had had a rotationplasty for reconstruction after resection of a tumor two years earlier, the patient elected to have a rotationplasty.
Three weeks after the last débridement failed to eradicate the infection (three months after the injury), a tibial rotationplasty was performed with the technique described for tumors by Salzer et al. and by Krajbich and Carroll13. The goal of the resection was to have the sole of the hindfoot at the level of the anterior edge of the proximal part of the flexed contralateral tibia. First, the sciatic nerve and the femoral (popliteal) artery and vein were dissected. After transection of the femoral muscles and subperiosteal elevation of the anterior tibial and triceps surae muscles, the femoral artery and vein were clamped. The femur and tibia were osteotomized, and the draining sinus and infected tissue about the knee were resected en bloc without exposing the knee. The tibia then was externally rotated nearly 180 degrees, and osteosynthesis of the proximal part of the femur to the proximal part of the tibia was accomplished with a broad six-hole limited-contact dynamic compression plate (Fig. 1-C). After shortening of both the artery and the vein, end-to-end anastomoses were performed. The sciatic nerve was kept intact, coiled, and placed anteromedial to the osteotomy site. The fascia of the anterior femoral muscles was sutured to the fascia of the triceps surae, and the fascia of the posterior femoral muscles was sutured to the fascia of the anterior tibial muscle. The operative wounds healed without complications, and the recovery was uneventful. The patient began partial weight-bearing with a temporary prosthesis on the eleventh postoperative day and full weight-bearing at twelve weeks, at which time plain radiographs showed union at the site of the osteosynthesis. The patient received the permanent prosthesis at nine months after the operation.
At the most recent follow-up examination, eighteen months after the rotationplasty and nine months after he received the permanent prosthesis, the patient was satisfied with the limb. He had no pain in the limb (including no phantom pain or pain due to a neuroma), he had noted continued functional improvement, and he had returned to work as a craftsman for approximately four hours a day. He reported swelling of the foot after working with the prosthesis on for three or four hours. He could walk a distance of five kilometers without aid. After walking for four hours or in association with changing weather, he had mild pain in the hip for which he did not need medication. He could ascend and descend stairs without supports or using the handrail, and he had no difficulty with walking on an incline or on uneven ground. However, he did have difficulty with getting into and out of automobiles and buses and with sitting in confined spaces (for example, in buses or in cinemas) because of limited flexion of the knee. He did not think that the limb was a cosmetic problem, and he wore shorts and bathing suits in public.
On physical examination, the prosthetic knee was found to be one centimeter distal to the level of the contralateral knee. The patient had hyperkeratosis on the dorsum of the foot, over the first, second, and fourth tarsometatarsal joints and the first metatarsal bone. The active range of flexion of the prosthetic knee was 3 to 75 degrees (Figs. 2-A, 2-B, 2-C, 2-D). Manual testing of motor strength revealed a grade of 5 of 5 for dorsiflexion and plantar flexion of the ankle. Gait analysis showed a pattern similar to that of someone who has had an above-the-knee amputation, with the knee extended at heel-strike. The free walking speed was normal, averaging (on four trials) eighty-nine meters per minute. (The normal speed ranges from eighty meters per minute3 to eighty-two meters per minute1, and the speed of someone who has had a traumatic above-the-knee amputation ranges from fifty-two meters per minute1 to sixty-six meters per minute9).
Rotationplasty was first described in 1930 as a treatment for ankylosis of the knee with limb-shortening following tuberculosis2. It has also been used to treat proximal femoral focal deficiency13,20. However, it has been used most frequently in children as a form of limb salvage after resection of malignant tumors about the knee4-7,12-15,17-19,21,22. Among the options that are available for the treatment of malignant tumors about the knee, rotationplasty is favored for its reliability and durability4-7,12-15,17-19,21,22. Patients who have had a rotationplasty are more active, have a more efficient gait, and are capable of faster free walking speeds than those who have had either an above-the-knee amputation or a knee arthrodesis8. The procedure is also associated with few complications7,12,13,22 and is psychologically well accepted by patients4,6,7,12,15,17,21,22.
Despite these favorable characteristics, the procedure has been infrequently performed in adults and has not been described previously, to our knowledge, for post-traumatic limb salvage. Rotationplasty was offered to our patient because he was young and active and had nearly normal function distal to the knee. The patient did not wish to have an arthrodesis of the knee with a secondary Syme amputation or limb-lengthening because such treatment is long and complicated, involving multiple operations. The other option, an above-the-knee amputation, would have been the most likely treatment at many centers because the mangled extremity severity score10 was more than 7 points.
In addition to the possible functional advantages of a rotationplasty compared with an above-the-knee amputation or an arthrodesis of the knee, other advantages include no breakdown of the stump, neuromas, or phantom pain. At the time of the most recent follow-up, the patient already had function similar to that reported following other operative options after tumor resection4,9,11,14,18, and he had shown continued improvement. Although the gait pattern was still unusual in that the knee was extended at heel-strike (a characteristic that is not found in subjects with normal limbs or subjects who have had a below-the-knee amputation and that has not been previously reported after rotationplasty5,18), the patient was able to return part-time to his previous work as a craftsman.
Rotationplasty can be a reasonable alternative for the treatment of severe injuries about the knee in selected young patients who have high functional demands and a functional foot and ankle. Additional study is needed to evaluate the long-term result for adults managed with this technique.