JBJS | Malignant Tumor of the Distal Part of the Femur or the Proximal Part of the Tibia: Endoprosthetic Replacement or Rotationplasty. Functional Outcome and Quality-of-Life Measurements*

The Journal of Bone & Joint Surgery, Volume 81, Issue 4

Articles | April 01, 1999

Malignant Tumor of the Distal Part of the Femur or the Proximal Part of the Tibia: Endoprosthetic Replacement or Rotationplasty. Functional Outcome and Quality-of-Life Measurements*

A. HILLMANN, M.D.†; C. HOFFMANN, M.D.†; G. GOSHEGER, M.D.†; H. KRAKAU, M.D.†; W. WINKELMANN, M.D.†, MÜNSTER, GERMANY

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Investigation performed at the Department of Orthopedics, Westfälische Wilhelms-Universität, Münster

The Journal of Bone & Joint Surgery. 1999; 81:462-8

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Abstract

Background: The present study was performed to determine whether there is a difference, with regard to functional outcome and quality of life, between endoprosthetic replacement and rotationplasty for the treatment of malignant tumors of the distal part of the femur or the proximal part of the tibia.Methods: Sixty-seven patients, between the ages of eleven and twenty-four years at the time of the diagnosis, had a malignant tumor of the distal part of the femur or the proximal part of the tibia. A rotationplasty was performed in thirty-three patients, and an endoprosthetic replacement was done in thirty-four patients. The median duration of follow-up was six years and one month (range, two years to sixteen years and two months). The scale developed by the Musculoskeletal Tumor Society was used to evaluate the functional results. Quality-of-life issues were assessed with the questionnaire developed by the European Organization for Research and Treatment of Cancer.Results: The patients who had had a rotationplasty had a mean functional score, according to the system of the Musculoskeletal Tumor Society, of 24 points, and the patients who had had an endoprosthetic replacement had a mean score of 25 points. This difference was not found to be significant, with the numbers available (p = 0.47). Only one patient who had had a rotationplasty used an assistive device when walking long distances, whereas six patients who had had an endoprosthetic replacement used an assistive device. This difference was significant (p < 0.001). The quality-of-life questionnaire revealed that the patients who had had a rotationplasty could participate in hobbies such as carpentry and sports as well as in other daily activities to a significantly greater degree than those who had had an endoprosthetic replacement (p = 0.001). Restriction in daily activities due to pain was significantly less common in the group that had had a rotationplasty than it was in the group that had had an endoprosthetic replacement (p = 0.047).Conclusions: Rotationplasty was not associated with any disadvantages with regard to function or quality of life in comparison with endoprosthetic replacement. It is possible that the psychosocial outcome is influenced by the fact that patients who have a rotationplasty know that additional operative intervention is not usually necessary. Despite good functional and quality-of-life results, the cosmetic appearance may be the most serious disadvantage of rotationplasty. The decision to perform this procedure must be made on a case-by-case basis.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The increase in the number of patients who survive with no evidence of disease after treatment of a malignant bone tumor has made it necessary to assess the quality of life and the functional outcome after various forms of treatment. Before the era of effective adjuvant chemotherapy, the treatment of a tumor around the knee was either a hip disarticulation or an above-the-knee amputation. Since the 1970s, malignant bone tumors around the knee have been treated with en bloc resection of the tumor and reconstruction of the defect with an endoprosthesis in most centers. Several authors have recommended rotationplasty as an alternative method of treatment in young children and in patients in whom the tumor has invaded the extensor mechanism of the knee joint^{3,4,8,11,16,29}.

In comparison with amputation, endoprosthetic replacement of the knee joint has been reported to be associated with good functional and cosmetic results and with psychological benefits^12,14,24. Gait analysis has shown that patients who have had an endoprosthetic replacement consume less oxygen than those who have had an amputation^18,21,22. Patients who have had a rotationplasty walk more efficiently and at a faster rate than those who have had an arthrodesis of the knee¹⁷.

Catani et al.⁵ assessed the kinetic, kinematic, and temporal-distance parameters of the gait of children who had had a rotationplasty. Although they found differences in stride length and velocity, related to age, the important conclusion that was reached by those authors was that the gait of patients who had had a rotationplasty was similar to that of normal subjects^5,23.

In most studies, the results of limb-salvage procedures (endoprosthetic replacement and arthrodesis of the knee) have been compared with those of amputation and rotationplasty. Rotationplasty has not been considered to be a limb-salvage procedure. However, we believe, on the basis of reports of good functional results in several studies^{4,8,16,19,25,29}, that rotationplasty should not be placed in the same category as an above-the-knee amputation. Instead, it should be compared with other limb-salvage procedures in assessments of functional outcome and quality of life.

We performed the present study to evaluate the effect of rotationplasty and endoprosthetic replacement on physical, psychological, and social function. To our knowledge, no previous investigators have performed such a comparison with use of the core quality-of-life questionnaire (QLQ-C30) of the European Organization for Research and Treatment of Cancer¹ and the functional score of the Musculoskeletal Tumor Society⁷, both of which are validated instruments.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedics, Westfälische Wilhelms-Universität, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany. E-mail address for Dr. Hillmann: hillmaa@uni-muenster.de.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedics, Westfälische Wilhelms-Universität, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany. E-mail address for Dr. Hillmann: hillmaa@uni-muenster.de.

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Fig. 1 Graph showing the mean functional scores (and standard deviations) according to the system of the Musculoskeletal Tumor Society⁷. A significant difference between the treatment groups was found with regard to the use of external supports for walking (p < 0.001).

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Fig. 2 Graph showing the mean scores (and standard deviations) according to the functional scales of the quality-of-life questionnaire (QLQ-C30) of the European Organization for Research and Treatment of Cancer¹. A significant difference between the treatment groups was found with regard to role functioning (p = 0.001).

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Fig. 3 Graph showing the mean scores (and standard deviations) for pain and financial difficulty according to the quality-of-life questionnaire (QLQ-C30) of the European Organization for Research and Treatment of Cancer¹. A significant difference between the two treatment groups was found with regard to restriction in activities due to pain (p = 0.047).

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

The surgeons and patients, or the patients' parents, reached a decision about the procedure to be performed after reviewing videotapes about three operations: endoprosthetic replacement with limb salvage, rotationplasty, and amputation. The expected functional result of each operation and the associated risks and consequences of local recurrence of the tumor were carefully described and discussed.

Endoprosthetic replacement with limb salvage was considered only when there was no evidence of invasion of the neurovascular structures by the tumor and when adequate function of the extremity after resection of the tumor could be anticipated. Patients who were not eligible for limb salvage but had no evidence of invasion of the neurovascular bundle, such as a large tumor involving the extensor mechanism, had a rotationplasty. Only patients who had a Van Nes rotationplasty were included in the study. Those who had a type-B rotationplasty were not considered for the study as it is necessary to reconstruct a hip joint (created with the original knee joint) or an articulation between the tibia and the acetabulum for that type of procedure²⁹.

A rotationplasty was performed in thirty-three patients and an endoprosthetic replacement, in thirty-four. The operations were performed between February 1980 and May 1996. The median age at the time of the diagnosis was sixteen years (range, eleven to twenty-four years) for the entire series of sixty-seven patients as well as for the group treated with endoprosthetic replacement (range, eleven to twenty-one years) and for the group treated with rotationplasty (range, eleven to twenty-four years). Twenty male patients and thirteen female patients had a rotationplasty, and twenty male patients and fourteen female patients had an endoprosthetic replacement.

Sixty-five patients had a high-grade malignant osteosarcoma, and two had a Ewing sarcoma. The distal part of the femur was involved in fifty-five patients (twenty-three who were managed with an endoprosthetic replacement and thirty-two who had a rotationplasty), and the proximal part of the tibia was involved in twelve patients (eleven who were managed with an endoprosthetic replacement and one who had a rotationplasty).

Sixty-six patients had chemotherapy and one had only regional irradiation in addition to the operative intervention. In this review, we included only patients who were no longer being managed with chemotherapy at the time of follow-up and who had been followed for at least two years after the operation. The interval of two years was chosen in order to provide sufficient time to overcome the effects of postoperative complications and chemotherapy-related toxicity on health-related quality of life.

Informed consent was obtained from all patients or their guardians before the follow-up evaluation. The median duration of follow-up was six years and one month (range, two years to sixteen years and two months).

Description of Assessment Instruments

Function was assessed with the scoring system developed by the Musculoskeletal Tumor Society, as described by Enneking et al.⁷. This score is based on an analysis of factors pertinent to the patient as a whole (pain, emotional acceptance, and restriction in activities of daily living and work) and factors specific to the affected extremity (use of external supports, walking ability, and gait). Each of these six factors was assigned a value of 0 to 5 points (maximum overall score, 30 points) on the basis of established criteria. This scoring system is an observer score.

Quality of life was assessed with use of the core quality-of-life questionnaire (QLQ-C30) of the European Organization for Research and Treatment of Cancer¹. This instrument incorporates nine multiple-item scales: five functional scales (physical, role, emotional, social, and cognitive), three symptom scales (fatigue, pain, and nausea and vomiting), and a global health and quality-of-life scale. In the functional scales a value of 100 points indicates that there is no restriction of the parameter, whereas in the symptom scales 100 points indicates the maximum severity of the symptom (for example, a score of 100 points for pain indicates a maximum degree of pain-related restriction). Several other, single-item symptom measures are included in the questionnaire.

Statistical Tests

One-way analysis of variance was employed to test for the significance of differences between the groups. The internal consistency of the multiple-item questionnaire scales was assessed with the Cronbach alpha coefficient^6,20. For ease of interpretation, all scale and item scores were linearly transformed to a scale of 0 to 100. The item responses for the five functional scales and the global quality-of-life scale were recorded so that a higher score represented a better level of functioning. With the symptom scales, a higher score corresponded with a higher intensity of symptoms.

Results

Introduction | Materials and Methods | Results | Discussion | References

Functional Results (Fig. 1)

According to the system of the Musculoskeletal Tumor Society⁷, the mean functional score was 24 of a maximum of 30 points for the patients who had had a rotationplasty and 25 points for those who had had an endoprosthetic replacement (p = 0.47).

Thirty (91 percent) of the thirty-three patients who had had a rotationplasty and thirty-one (91 percent) of the thirty-four patients who had had an endoprosthetic replacement had either no or only slight pain and did not need any analgesic medication. Three patients (9 percent) who had had a rotationplasty occasionally used non-narcotic analgesics or reported mild pain. The reasons for the pain were related to a poorly fitting prosthesis, skin ulceration, or subluxation of the ankle joint with instability. One patient (3 percent) who had had an endoprosthetic replacement used narcotics on a daily basis, and two (6 percent) regularly used non-narcotic analgesics; all three had a distal femoral endoprosthesis. The patient who used narcotics had radiographic evidence of a loose stem, mild clinical instability, and muscle weakness; the other two patients had pain with weight-bearing activities.

A restriction in activities (a score of 0 to 3 points) related to work was recorded for one patient (3 percent) who had had a rotationplasty. This patient was unemployed after operative intervention as he could not meet the requirements of his former job, which included long hours of standing and walking. The patient had not been retrained at the time of the latest follow-up evaluation. Six patients (18 percent) who had an endoprosthesis reported restriction in activities related to work, especially when the job was physically demanding. Two of the six patients were unemployed. The number of patients going to school was equal in the two groups.

Emotional acceptance was assessed by asking the patients whether, given the same circumstances, they would choose the same procedure and whether they would recommend the procedure to other patients in a similar situation. Twenty-eight patients (82 percent) who had had an endoprosthetic replacement and twenty-seven (82 percent) who had had a rotationplasty were convinced (a score of 4 or 5 points) about the effectiveness of the procedure.

Only one patient (3 percent) who had had a rotationplasty used an assistive device (in addition to the exoprosthesis) when walking compared with six patients (18 percent) who had had an endoprosthetic replacement. This difference was significant (p < 0.001). The reasons for the use of an additional support by the patients who had an endoprosthesis were weakness of the muscles or pain after walking a long distance. The patients often used a cane or crutch because of a feeling of insecurity when walking outside the home. The one patient who used a walking aid after a rotationplasty had an axial malalignment of the tibia secondary to a traumatic fracture of the distal part of the tibia. The crutch was necessary during prolonged walking to improve stability and to take weight off of the affected extremity. None of the patients used two crutches. All of the patients who had had a rotationplasty wore the exoprosthesis during their activities of daily living.

Postoperatively, seven (21 percent) of the thirty-three patients who had had a rotationplasty and nine (26 percent) of the thirty-four patients who had an endoprosthesis were limited with regard to the distance that they could walk (a score of 0 to 3 points) (p = 0.7). One of us (C. H.) evaluated the gait of all patients, and videotapes made during gait analysis were assessed by three of us (A. H., C. H., and G. G.). With the number of patients available for study, we could not detect any differences in the scores for gait between the two groups (p = 0.69). The gait of twenty-seven patients (79 percent) who had had an endoprosthetic replacement was graded as normal or a slight or minor cosmetic deficiency (a score of 5, 4, or 3 points), and that of seven patients (21 percent) was graded as a major cosmetic deficiency or a minor or major functional alteration (a score of 2, 1, or 0 points). Two patients who had had a rotationplasty had a major cosmetic deficiency and a minor functional alteration (a score of 1 point) (p = 0.69).

Analysis of the functional results in separate age-groups revealed that the treatment groups still differed with regard to the use of external supports (eleven to fifteen-year age-group, p = 0.011; sixteen to twenty-four-year age-group, p = 0.007), whereas with the numbers available we still were unable to detect any significant differences in the results of gait analysis or in the distance and duration of walking.

Quality-of-Life Analysis1

Sixty-five patients (thirty-two of the thirty-three who had had a rotationplasty and thirty-three of the thirty-four who had had an endoprosthetic replacement) completed the quality-of-life questionnaire (QLQ-C30)¹. The median quality-of-life score for evaluation of general health for both groups was 80 points. Twenty-three (72 percent) of the thirty-two patients who had had a rotationplasty and twenty-five (76 percent) of the thirty-three who had had an endoprosthetic replacement rated their health as good or excellent. Using analysis of variance, we did not detect any significant difference (p = 0.89).

Questions about limitation of the ability to perform tasks related to hobbies, work, and other daily activities (role functioning) revealed that twenty-five (78 percent) of the patients who had had a rotationplasty had a high level of work-related and sports activity compared with fourteen (42 percent) of the patients who had had an endoprosthetic replacement. The median score (and standard deviation) was 80 ± 16.1 points for the patients who had had a rotationplasty compared with 60 ± 20.6 points for those who had an endoprosthesis. The difference was significant (p = 0.001) (Fig. 2).

With the numbers available, we were not able to detect any significant differences between the groups with regard to the scores for the other functional scales. The median score for physical functioning was 100 ± 14.3 points for the patients who had had a rotationplasty and 100 ± 15.6 points for those who had an endoprosthesis (p = 0.290), the median score for social functioning was 100 ± 18.4 points for the patients who had had a rotationplasty and 80 ± 23.9 points for those who had an endoprosthesis (p = 0.295), and the median score for emotional functioning was 100 ± 17.9 points for the patients who had had a rotationplasty and 80 ± 18.5 points for those who had an endoprosthesis (p = 0.55).

The evaluation with use of the symptom scales showed that most of the patients who had had a rotationplasty had no restriction in daily activities due to pain, with an excellent median score of 0 points (mean and standard deviation, 14.3 ± 21.0 points). The score (median, 20 points; mean and standard deviation, 26.06 ± 25.2 points) was significantly different (p = 0.047) for the patients who had had an endoprosthetic replacement (Fig. 3). No restriction or only mild restriction in daily activities secondary to pain (0 to 40 points) was reported by twenty-nine (91 percent) of the patients who had had a rotationplasty compared with twenty-five (76 percent) of those who had had an endoprosthetic replacement. Three (9 percent) of the patients who had had a rotationplasty reported some restriction due to mild pain (60 points) compared with seven (21 percent) of those who had an endoprosthesis. One patient who had an endoprosthesis had severe restriction (80 points). We could not detect any significant difference between the groups with regard to scores according to the other symptom scales (fatigue and nausea and vomiting).

Analysis of the quality of life in separate age-groups revealed the same significant differences between treatment groups with regard to role functioning (eleven to fifteen-year age-group, p = 0.023; sixteen to twenty-four-year age-group, p = 0.014). However, we could detect no significant difference in terms of restriction in activities due to pain (eleven to fifteen-year age-group, p = 0.174; sixteen to twenty-four-year age-group, p = 0.156).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

An increasing number of young children and adults who have a malignant tumor survive disease-free after treatment; thus, it is essential that the different operative procedures be assessed in terms of functional and psychosocial outcome with use of standardized measurement instruments⁷. There is little information in the literature about the functional and psychosocial adjustment of children and young adults who have had a limb-salvage procedure. Several investigators^24,26,28 were unable to demonstrate a difference in psychosocial adjustment or in quality of life between patients who had had an amputation and those who had had a limb-salvage procedure. Harris et al.¹⁰ reported that patients who had had an arthroplasty had higher scores for self-concept and that they felt more normal, acceptable in terms of their appearance, optimistic, useful, worthy, and successful compared with patients who had had an arthrodesis. Boyle et al.² found that if a patient had no previous psychological disorder the psychosocial adjustment was not influenced by the type of procedure that had been performed.

In our study, the patients who had had a rotationplasty had a better score for role functioning (hobbies, work, and other daily activities) and less restriction with regard to activities of daily living because of pain compared with the patients who had had an endoprosthetic replacement.

The use of an assistive device for walking, especially on uneven ground or slippery surfaces, due to weakness of the extensor mechanism of the knee was more frequent after the endoprosthetic replacements. The reason for the use of a cane or crutch was often explained as a feeling of insecurity when walking long distances. The patients were able to descend stairs one step at a time. Harris et al.¹⁰ described similar results. Cammisa et al.³ reported that loosening of the prosthesis or instability due to axial malalignment could not be compensated for with muscle force. Those authors³ showed that the net energy cost increased approximately 20 percent after loosening of an endoprosthesis. In our study, only one patient who had had a rotationplasty used an assistive device, and that patient had a deviation in the axis of the tibia after a traumatic fracture. This patient needed extensive gait-training and used the assistive device during this period of training.

Functional data and the findings of gait analysis have been reported in several studies^{5,10,17,18,27}. Cammisa et al.⁴ reported that the results of functional tests, including assessment of oxygen consumption and gait analysis, after rotationplasty were equivalent to those after endoprosthetic replacement. In fact, they found that the net energy expended during walking was less after a rotationplasty than it was after an above-the-knee amputation or an endoprosthetic replacement. In our study, the patients who had had a rotationplasty had as good results with regard to gait and walking distance as those who had an endoprosthesis.

In most reports, pain is not mentioned as a reason for restriction in activities. Rougraff et al.²⁴ could not find any differences with regard to pain or acceptance of the results (emotional adjustment) among patients who had had a limb-salvage procedure, an above-the-knee amputation, or a hip disarticulation. However, the quality-of-life assessment in that study showed that only eighteen of twenty-nine patients had no pain, and two patients had severe pain. In our study, only a small number of patients in both groups needed additional medication; however, restriction in daily activities because of slight or moderate pain was noted on the quality-of-life questionnaire by a number of patients, especially those who had had an endoprosthetic replacement. Weakness of the muscles may lead to instability, thereby causing pain in the region of the knee. After a rotationplasty, an unsatisfactory fit of the new exoprosthesis or early degenerative disease of the ankle joint may sometimes cause pain. In our study, one female patient, who was very slender, continued to have problems related to the fit of the prosthesis. Seven years after the operation, she still had pain with weight-bearing activities.

The cosmetic results of rotationplasty have been frequently discussed in the literature. Fixsen⁹ and Kostuik et al.¹⁵ expressed concern about the psychological problems that may arise from the unusual appearance of the rotated foot. Finn and Simon⁸ believed that the advantage of rotationplasty was that it provided a biological method of durable reconstruction but that the cost to the patient was a bizarre appearance. Several investigators have noted that even though children who have had a rotationplasty require a prosthesis they do not think of themselves as amputees because the foot has been retained^3,12-14. Other authors^11,16,29 have reported that their patients were not bothered by the appearance of the limb and regarded the procedure as an operation to save the limb rather than as an amputation. These patients felt that the mobility that they achieved far outweighed the unusual appearance.

In our study, both the patients who had had a rotationplasty and those who had an endoprosthesis were satisfied with the outcome of the procedure. However, adaptation in daily life differed between the two groups. The patients who had had a rotationplasty adjusted well to the functional outcome of the procedure and to the disease. They were very active, participating in sports activities such as badminton, in-line skating, cycling, skiing, and squash. The patients who had had an endoprosthetic replacement led more sedentary lives. They often focused their emotional and physical efforts on saving the extremity because of a fear of destroying the endoprosthesis. These differences in outlook, adjustment, and ability to participate in various activities may account for the better results with regard to quality-of-life issues after the rotationplasties.

The better results with regard to role functioning, and the absence of differences with regard to social and emotional functioning, suggest that there is no psychosocial disadvantage to rotationplasty, despite the degree of mutilation. Notwithstanding the good role functioning, the cosmetic appearance seemed to be an important factor, especially to adolescent patients; however, we did not find a noticeable reduction in score related to either age or gender. In fact, the impact of the appearance of the extremity was greater on the observer than on the patient. Thus, our study showed that rotationplasty was not associated with any disadvantages in function or quality of life compared with endoprosthetic replacement and that it therefore can be considered a good alternative procedure.

The decision to perform a rotationplasty must be made independently for each patient. Ethnic or religious issues can overrule the expected functional advantage. Thus, in some patients, an above-the-knee amputation may be necessary when limb salvage with an arthroplasty cannot be performed because of oncological reasons and rotationplasty is unacceptable to the patient. The results of this study may help surgeons and patients to assess the advantages and disadvantages of each procedure.

References

Introduction | Materials and Methods | Results | Discussion | References

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