ROTATIONPLASTY
Limb Salvage Alternative | Ankle-to-Knee Conversion | Borggreve-Van Nes Procedure
Van Nes Classification (Rotationplasty Types)
Critical Must-Knows
- Rotationplasty rotates the distal limb 180 degrees so ankle functions as knee joint
- Ideal candidates: skeletally immature patients with distal femur or proximal tibia tumours
- Functional outcomes often superior to above-knee amputation with MSTS scores 75-85%
- Position the heel 2-3cm above contralateral knee joint to allow for growth
- Psychological preparation and patient selection are critical for success
Examiner's Pearls
- "Know the Van Nes classification and which type applies to distal femur versus proximal tibia tumours
- "Sciatic nerve preservation is critical - must maintain at least 15cm length
- "Discuss the cosmetic versus functional trade-off in patient counselling
- "Compare outcomes with above-knee amputation and endoprosthetic replacement
Critical Rotationplasty Exam Points
Patient Selection
Ideal candidate: Skeletally immature child (age 6-12) with distal femur or proximal tibia tumour. Requires intact sciatic nerve, adequate vessel length, and no metastatic disease. Psychological assessment and family counselling are mandatory.
180-Degree Rotation
The limb is rotated 180 degrees so that plantarflexion of the ankle produces knee extension motion. The rotated ankle joint becomes the functional knee joint, powered by the gastrocnemius-soleus complex.
Positioning the Heel
Position heel 2-3cm above contralateral knee in growing children to account for growth potential. This ensures the prosthetic knee joint aligns properly at skeletal maturity. Too high causes leg length inequality.
Functional Outcomes
MSTS scores 75-85% - often superior to above-knee amputation (60-70%) and comparable to endoprosthetic replacement. Patients can run, jump, swim, and participate in sports. No stump issues or revision surgeries.
At a Glance
Rotationplasty (Borggreve-Van Nes procedure) is a limb-salvage surgical technique used primarily for malignant bone tumours of the distal femur or proximal tibia in skeletally immature patients. The procedure involves en bloc resection of the tumour-bearing segment followed by 180-degree rotation of the distal limb, so that the ankle joint becomes the functional knee joint. The rotated foot is then fitted with a below-knee prosthesis. First described by Borggreve in 1930 and later popularized by Van Nes, this technique offers superior functional outcomes (MSTS 75-85%) compared to above-knee amputation (60-70%) while avoiding the complications associated with expandable endoprostheses in growing children. Despite its unusual cosmetic appearance, long-term studies demonstrate excellent quality of life and psychological adaptation in appropriately selected and counselled patients.
ROTATERotationplasty Indications
Memory Hook:ROTATE the limb for tumour resection when the patient can emotionally and physically adapt!
TWISTSurgical Principles
Memory Hook:TWIST the leg to create a new functional knee joint!
SKIPContraindications
Memory Hook:SKIP rotationplasty if these contraindications exist!
Overview and Historical Context
Definition
Rotationplasty is a limb-salvage surgical technique that converts the ankle joint into a functional knee joint through 180-degree rotation of the distal limb segment following en bloc resection of bone tumours affecting the distal femur or proximal tibia. The procedure preserves the neurovascular structures to the distal limb, allowing active ankle motion (now functioning as knee flexion/extension) and proprioceptive feedback.
Historical Development
Evolution of Rotationplasty
German surgeon Kuno Borggreve first described rotationplasty for a patient with severe tuberculous arthritis of the knee, demonstrating that the rotated ankle could function as a knee joint.
Dutch orthopaedic surgeon C.P. Van Nes popularized the technique for congenital proximal femoral focal deficiency (PFFD), establishing classification system.
Austrian surgeons applied rotationplasty to malignant bone tumours, demonstrating oncological safety and functional benefits in children.
Winkelmann and others refined surgical technique, patient selection criteria, and rehabilitation protocols. Long-term outcome studies confirm excellent functional results and psychological adaptation.
Historical Context for Exams
In the viva, know that Borggreve first described rotationplasty in 1930, but Van Nes popularized it for congenital conditions (PFFD) in 1950 - hence the eponymous "Van Nes rotationplasty". Salzer applied it to oncology in 1981. This demonstrates the procedure evolved from non-oncological to oncological applications.
Epidemiology and Indications
Primary Indications:
- Osteosarcoma of distal femur or proximal tibia in skeletally immature patients
- Ewing sarcoma of distal femur or proximal tibia
- Aggressive benign tumours (GCT, ABC) with extensive bone destruction
Patient Demographics:
- Typical age: 6-14 years (skeletally immature)
- Peak incidence matches osteosarcoma demographics (10-20 years)
- No gender predilection for the procedure itself
Rotationplasty vs Above-Knee Amputation vs Endoprosthetic Replacement
| Feature | Rotationplasty | Above-Knee Amputation | Endoprosthetic Replacement |
|---|---|---|---|
| Functional outcome (MSTS) | 75-85% (excellent) | 60-70% (moderate) | 70-80% (good) |
| Running and sports | Yes - active participation | Limited - high-activity prostheses | Limited - implant protection |
| Revision surgery | Rarely needed | Stump revision 15-20% | Multiple revisions required (growing child) |
| Infection risk | Low (no implant) | Low | 10-15% deep infection |
| Cosmetic appearance | Unusual - rotated foot visible | Limb absence | Near-normal appearance |
| Psychological adaptation | Excellent with proper counselling | Variable - phantom limb issues | Good |
| Long-term durability | Permanent biological solution | Stump issues common | Implant loosening 5-10 years |
| Growing child suitability | Ideal - accommodates growth | Acceptable | Problematic - multiple lengthenings |
Anatomy and Biomechanics
Key Anatomical Considerations
Sciatic Nerve
The sciatic nerve must be carefully preserved and mobilised to allow 180-degree rotation without tension. Minimum 15cm of nerve length is required. The nerve courses posteriorly, providing motor innervation to hamstrings and all leg/foot muscles below the knee.
Femoral Vessels
The femoral artery and vein transition to popliteal vessels behind the knee. These must be mobilised adequately to rotate without kinking or tension. Vessel length is critical - short vessels are a relative contraindication.
Ankle Joint
After rotation, the ankle becomes the functional knee joint. Plantarflexion produces knee extension, dorsiflexion produces knee flexion. The gastrocnemius-soleus complex becomes the "quadriceps equivalent".
Tibialis Anterior
The tibialis anterior muscle (dorsiflexor) becomes the "hamstring equivalent" after rotation, producing knee flexion. This preserves active motor control of the new joint.
Biomechanics of the Rotated Limb
After rotationplasty, the biomechanics of the lower limb are fundamentally altered:
Muscle Function Conversion:
- Gastrocnemius-soleus (ankle plantarflexors) become knee extensors
- Tibialis anterior (ankle dorsiflexor) becomes knee flexor
- Peroneal muscles contribute to knee flexion
- Triceps surae reflex becomes functionally equivalent to quadriceps reflex
Joint Mechanics:
- Ankle joint provides 20-45 degrees of "knee" flexion/extension
- Proprioceptive feedback maintained through intact sensory nerves
- The calcaneus becomes weight-bearing through the prosthetic socket
Biomechanics Viva Point
Key examiner question: "How does the patient extend the knee after rotationplasty?" Answer: "Plantarflexion of the ankle (gastrocnemius-soleus contraction) produces knee extension because the limb is rotated 180 degrees. The former ankle plantarflexors become the functional quadriceps equivalent."
Classification
Van Nes Classification System
The Van Nes classification categorizes rotationplasty procedures based on the location of tumour resection and the level of osteosynthesis:
Type A Rotationplasty (Van Nes Procedure)
Indication: Proximal tibia tumours
Technique:
- Resection of proximal tibia including tumour
- Distal tibial segment rotated 180 degrees
- Arthrodesis between femoral condyles and distal tibia
- Foot positioned to function as prosthetic knee joint
Osteosynthesis Level: Tibiofemoral fusion (distal tibia to distal femur)
Key Points:
- Preserves the knee joint capsule attachments to femur
- Fewer vascular challenges than Type B
- Less limb shortening compared to femoral resection
Van Nes Classification Summary
| Type | Tumour Location | Resection Level | Osteosynthesis | Common Tumour |
|---|---|---|---|---|
| Type A | Proximal tibia | Proximal tibia | Tibia to distal femur | Osteosarcoma, Ewing sarcoma |
| Type B1 | Distal femur | Distal femur | Tibia to proximal femur | Osteosarcoma (most common) |
| Type B2 | Femoral diaphysis | Extended femur | Tibia to trochanteric region | Diaphyseal tumours |
| Type C | Proximal femur/hip | Proximal femur | Tibia to pelvis | Rare for tumours |
Patient Selection and Counselling
Ideal Patient Characteristics
Medical Criteria
- Age 6-14 years (skeletally immature)
- Tumour resectable with clear margins
- No metastatic disease (or controlled oligometastatic)
- Intact sciatic nerve (not encased by tumour)
- Adequate femoral vessel length for rotation
- No prior radiation to surgical field
Tumour Characteristics
- Distal femur or proximal tibia location
- Responsive to neoadjuvant chemotherapy (if indicated)
- No major vessel or nerve invasion
- Adequate soft tissue envelope preserved
- Sufficient residual limb length post-resection
Contraindications
Absolute Contraindications
Do not perform rotationplasty if:
- Sciatic nerve encasement or invasion by tumour
- Femoral artery or vein invasion requiring resection
- Inadequate vessel length for 180-degree rotation
- Active metastatic disease with poor prognosis
- Patient/family unable to accept cosmetic outcome after counselling
Relative Contraindications:
- Skeletal maturity (adolescents near skeletal maturity may prefer other options)
- Extensive soft tissue involvement requiring skin grafting
- Prior radiation compromising wound healing
- Ipsilateral foot or ankle pathology limiting function
- Severe psychological concerns despite counselling
Psychological Preparation
Counselling Process
Detailed explanation of all treatment options (rotationplasty, AKA, endoprosthesis). Show videos and photos of rotationplasty outcomes. Allow patient and family to meet previous rotationplasty patients.
Psychology assessment for patient and family. Evaluate coping mechanisms, support systems, and understanding of altered body image. Social work involvement for practical considerations.
Ensure understanding of: cosmetic appearance, functional expectations, prosthetic requirements, rehabilitation timeline, potential complications. Document shared decision-making.
Connect with age-appropriate previous rotationplasty patients. Observe prosthetic fitting and function. Address specific concerns about activities and social interactions.
Psychological Counselling
Examiner question: "How do you counsel a family considering rotationplasty?" Key points to mention: (1) Functional superiority over AKA with MSTS 75-85%; (2) Unusual cosmetic appearance - show images and videos; (3) Meet previous patients; (4) Psychological assessment mandatory; (5) Long-term studies show excellent psychological adaptation; (6) Shared decision-making documented; (7) Option to decline and choose alternative.
Surgical Technique
Borggreve Rotationplasty (Type B - Distal Femur)
The most common rotationplasty for oncological indications.
Surgical Steps - Borggreve Rotationplasty
- Supine position on radiolucent table
- Entire limb draped free for manipulation
- Cell saver available for blood conservation
- Image intensifier positioned for intraoperative imaging
- Sterile tourniquet available but not routinely used
- Longitudinal incision from mid-thigh to mid-calf
- Plan incision to include biopsy tract for excision
- Develop flaps to expose femur and proximal tibia
- Identify and protect femoral vessels and sciatic nerve
- Identify femoral vessels at adductor hiatus
- Ligate profunda femoris if necessary for mobilisation
- Mobilise femoral artery and vein proximally
- Identify sciatic nerve in posterior thigh
- Mobilise nerve with at least 15cm length preserved
- Mark proximal femoral osteotomy level (above tumour margin)
- Mark distal tibial osteotomy level (below tumour margin)
- Perform en bloc resection maintaining wide oncological margins
- Send specimen for pathology - confirm margins frozen section
- Preserve femoral and tibial periosteum at osteotomy sites
- Externally rotate the distal limb segment 180 degrees
- Ensure vessels and nerve are not kinked or under tension
- Check vascular flow with Doppler after rotation
- The heel should now face anteriorly (toward surgeon)
- Toe points posteriorly
- Position the heel 2-3cm above the contralateral knee level
- This accounts for remaining growth in skeletally immature patients
- May need to shorten tibia to achieve correct positioning
- Confirm length clinically with comparison to opposite side
- Approximate proximal femur to proximal tibia
- Achieve stable fixation with:
- Intramedullary nail (preferred for stable fixation)
- Locking plate and screws
- External fixation (for contaminated cases or poor bone)
- Confirm alignment and rotation clinically
- Check radiographically with image intensifier
- Confirm vascular supply to rotated foot (Doppler, capillary refill)
- Layered closure of fascia and subcutaneous tissue
- Skin closure without tension - may need delayed closure or skin graft
- Splint in neutral ankle position (equivalent to knee extension)
- Well-padded dressing, avoid circumferential compression
Technical Pearls
- Preserve sciatic nerve carefully with meticulous dissection
- Ligate branches of profunda for vessel mobilisation
- Check vascular flow with Doppler BEFORE committing to rotation
- Verify limb length by comparison to contralateral side
- Position heel 2-3cm above contralateral knee for growth
Pitfalls to Avoid
- Vessel kinking after rotation (leads to ischemia)
- Sciatic nerve tension (causes paresis)
- Incorrect rotation angle (not full 180 degrees)
- Wrong leg length (too long or too short)
- Inadequate tumour margins (oncological failure)
Osteosynthesis Options
Fixation Methods for Rotationplasty
| Method | Advantages | Disadvantages | Best Indication |
|---|---|---|---|
| Intramedullary Nail | Excellent stability, early mobilisation | Requires adequate canal diameter | Standard choice for adolescents |
| Locking Plate | Preserves bone stock, versatile | Less stable than nail, soft tissue irritation | Small bone, young children |
| External Fixation | No implant in bone, allows adjustment | Pin site infection, patient inconvenience | Infected cases, staged procedures |
| Combination | Customised stability | More hardware | Complex cases, poor bone quality |
Intraoperative Vascular Assessment
Before completing rotation:
- Check femoral/popliteal pulse with Doppler
- Assess capillary refill in toes
- Confirm no vessel kinking or compression
- If any concern - de-rotate and reassess
Vascular compromise requires immediate intervention - liaise with vascular surgery if needed.
Complications
Early Complications
Early Postoperative Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Vascular compromise | 2-5% | Short vessels, excessive tension, vessel kinking | Immediate exploration, de-rotation, vascular repair |
| Nerve palsy (temporary) | 5-10% | Sciatic nerve stretch, inadequate mobilisation | Observation, physio - most recover within 6 months |
| Wound complications | 10-15% | Prior chemotherapy, tension, radiation | Dressings, VAC therapy, delayed closure, skin graft |
| Deep infection | 3-5% | Immunosuppression, wound breakdown | Debridement, antibiotics, may need hardware removal |
| Compartment syndrome | Less than 2% | Vascular compromise, tight dressings | Urgent fasciotomy |
Late Complications
Late Postoperative Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Nonunion | 5-10% | Chemotherapy, poor fixation, infection | Revision surgery, bone grafting, improved fixation |
| Malrotation | Less than 5% | Technical error, growth asymmetry | Revision osteotomy if symptomatic |
| Leg length discrepancy | 10-20% | Growth disturbance, incorrect initial positioning | Prosthetic adjustment, rarely surgical lengthening |
| Local recurrence | 5-10% | Inadequate margins, aggressive tumour | Salvage amputation, systemic therapy |
| Psychological distress | Variable | Inadequate counselling, poor support | Psychological support, peer counselling |
Postoperative Management
Immediate Postoperative Care
Postoperative Protocol
- Neurovascular checks every 2 hours (critical)
- Pain management with multimodal analgesia
- Elevation of limb on pillows
- Ankle splint in neutral position (represents knee extension)
- DVT prophylaxis (mechanical and pharmacological)
- Monitor for compartment syndrome in calf muscles
- Continue neurovascular monitoring
- Wound checks and drain removal
- Begin gentle ankle range of motion exercises
- Non-weight bearing mobilisation with crutches/wheelchair
- Psychology and social work support initiated
- Progressive ankle ROM exercises
- Non-weight bearing continued until fusion signs
- Serial X-rays to assess union at fusion site
- Begin stump conditioning for prosthetic fitting
- Psychological support continued
- Confirm radiographic union (typically 8-12 weeks)
- Progress to protected weight bearing once united
- Prosthetic fitting and gait training initiated
- Continue ankle strengthening exercises
- Return to school planning
- Full weight bearing through prosthesis
- Progressive activity and sports participation
- Prosthetic adjustments as needed
- Long-term oncological surveillance commenced
Prosthetic Considerations
Prosthetic Design
- Below-knee (transtibial) type prosthesis fitted
- Socket encompasses the rotated foot
- Energy-storing prosthetic foot at distal end
- Prosthetic "knee" joint at ankle level
- Active ankle motion produces knee function in prosthesis
Gait Training
- Teach plantarflexion for knee extension (stance phase)
- Dorsiflexion initiates swing phase (knee flexion)
- Weight transfer through heel of rotated foot
- Running and sports achievable with practice
- Typically independent gait by 3-6 months
Outcomes and Prognosis
Functional Outcomes
MSTS Scores
- Rotationplasty: 75-85% (excellent)
- Above-knee amputation: 60-70% (moderate)
- Endoprosthetic replacement: 70-80% (good)
Higher scores reflect better walking, running, and activity participation.
Activity Level
- Running: Achievable in most patients
- Jumping: Possible with training
- Swimming: Excellent - preferred activity
- Cycling: May require adapted equipment
- Team sports: Soccer, basketball participation reported
Psychological Outcomes
Long-term studies (10+ year follow-up) demonstrate:
- Excellent psychological adaptation in appropriately selected patients
- Quality of life scores comparable to healthy peers
- High satisfaction rates (greater than 85% would choose rotationplasty again)
- Body image concerns decrease over time
- Children adapt more readily than adolescents
Outcome Data for Exams
Know these numbers:
- MSTS functional score: 75-85% (superior to AKA 60-70%)
- Patient satisfaction: greater than 85% would choose again
- Major complication rate: 5-15%
- Nonunion rate: 5-10%
- Local recurrence: depends on tumour factors, not procedure
Evidence Base
Long-term Functional Outcomes of Rotationplasty
- 31 patients with mean follow-up of 14 years after rotationplasty
- Mean MSTS functional score of 80% (range 60-97%)
- Gait analysis showed near-normal walking patterns
- No significant decline in function over long-term follow-up
- Quality of life comparable to age-matched healthy controls
Psychological Adaptation to Rotationplasty
- 33 rotationplasty patients compared to 26 above-knee amputees
- No significant difference in psychological distress between groups
- Body image concerns similar at long-term follow-up
- Rotationplasty patients reported higher activity levels
- Younger age at surgery associated with better psychological adaptation
Comparison of Rotationplasty, AKA, and Endoprosthesis
- Meta-analysis of functional outcomes across reconstruction types
- Rotationplasty MSTS scores 75-85%, superior to AKA (60-70%)
- Endoprosthetic replacement MSTS 70-80%, but higher revision rate
- Complication rates similar across groups
- Rotationplasty ideal for growing children due to growth accommodation
Gait Analysis After Rotationplasty
- Detailed biomechanical analysis of rotationplasty gait
- Active ankle (now knee) motion provides 20-45 degrees of flexion/extension
- Preserved proprioception allows near-normal gait patterns
- Energy expenditure lower than above-knee amputees
- Running and athletic activities biomechanically achievable
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Initial Presentation and Treatment Options
"A 10-year-old boy presents with a 6-week history of right distal femur pain. Imaging reveals a destructive lesion consistent with osteosarcoma. Staging shows no metastatic disease. The tumour involves the distal 15cm of femur but spares the neurovascular structures. What are the reconstructive options and which would you recommend?"
Scenario 2: Surgical Technique Discussion
"You are performing a Borggreve rotationplasty for distal femur osteosarcoma in a 12-year-old girl. Describe the critical steps of the procedure and the key technical considerations."
Scenario 3: Complications and Outcomes
"A 14-year-old girl is now 2 years post-rotationplasty for proximal tibial osteosarcoma. She is struggling with body image issues and asking whether she made the right choice. Her parents are concerned. How do you approach this situation?"
Australian Context
Australian Practice
In Australia, rotationplasty is performed at specialised paediatric orthopaedic oncology centres, typically within major children's hospitals with established sarcoma services. The procedure requires a multidisciplinary team including orthopaedic oncology surgeons, plastic surgeons for soft tissue coverage, vascular surgeons for complex cases, paediatric oncologists, specialized prosthetic services, and psychological support teams.
Access to rotationplasty services is available through the public hospital system at no direct cost to families. The Royal Children's Hospital Melbourne, Children's Hospital Westmead Sydney, Queensland Children's Hospital Brisbane, and Perth Children's Hospital all have established programs. Pre-operative assessment, surgery, rehabilitation, prosthetic fitting, and long-term follow-up are covered under Medicare and state hospital funding.
Prosthetic services following rotationplasty are supported through various funding mechanisms including the National Disability Insurance Scheme (NDIS) for eligible patients, state-based prosthetic programs, and hospital prosthetic departments. Initial fitting, replacement prostheses during growth, and activity-specific prosthetic components are generally accessible, though wait times and specific coverage vary by state. Long-term oncological surveillance aligns with Australian and New Zealand Sarcoma Association (ANZSA) guidelines, with imaging and clinical review coordinated through the treating sarcoma unit.
Rotationplasty - Exam Summary
High-Yield Exam Summary
Definition and Indication
- •180-degree rotation of distal limb converting ankle to functional knee
- •Primary indication: distal femur or proximal tibia tumours in children
- •Ideal age: 6-14 years (skeletally immature)
- •Van Nes classification: Type A (proximal tibia), Type B (distal femur), Type C (proximal femur)
Key Surgical Points
- •Sciatic nerve needs minimum 15cm length preserved
- •Check vascular flow with Doppler BEFORE rotation
- •Rotate EXACTLY 180 degrees (heel anterior)
- •Position heel 2-3cm above contralateral knee for growth
- •Osteosynthesis: IM nail, plate, or external fixation
Functional Outcomes
- •MSTS score: 75-85% (superior to AKA 60-70%)
- •Plantarflexion produces knee extension (gastrocnemius = quadriceps)
- •Running, jumping, sports participation achievable
- •Proprioception preserved through intact nerves
- •Below-knee prosthesis fitted to rotated foot
Complications
- •Vascular compromise: 2-5% (requires immediate de-rotation)
- •Nerve palsy (temporary): 5-10%
- •Wound complications: 10-15%
- •Nonunion: 5-10%
- •Psychological distress: variable (counselling essential)
Patient Selection
- •Psychological assessment mandatory
- •Family to meet previous patients
- •Shared decision-making documented
- •Contraindication: sciatic nerve involvement, short vessels, unable to accept cosmesis
- •Greater than 85% would choose rotationplasty again in long-term studies
Comparison with Alternatives
- •vs AKA: better function (75-85% vs 60-70%), can run/jump
- •vs Endoprosthesis: avoids multiple revisions, no infection risk
- •Cosmesis: unusual appearance (rotated foot) vs prosthetic limb vs near-normal
- •Durability: permanent biological solution vs stump issues vs implant loosening
References
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Borggreve J. Kniegelenkersatz durch das in der Beinlangsachse um 180 Grad gedrehte Fussgelenk. Arch Orthop Trauma Surg. 1930;28:175-178.
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Van Nes CP. Rotation-plasty for congenital defects of the femur. J Bone Joint Surg Br. 1950;32-B(1):12-16.
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Salzer M, Knahr K, Kotz R, Zielinski C. Treatment of osteosarcomata of the distal femur by rotation-plasty. Arch Orthop Trauma Surg. 1981;99(2):131-136.
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Winkelmann WW. Rotationplasty. Orthop Clin North Am. 1996;27(3):503-523.
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Hillmann A, Hoffmann C, Gosheger G, et al. Rotationplasty - surgical treatment modality after failed limb salvage procedure. Arch Orthop Trauma Surg. 2007;127(9):727-732.
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Veenstra KM, Sprangers MA, van der Eyken JW, Taminiau AH. Quality of life in survivors with a Van Nes-Borggreve rotationplasty after bone tumour resection. J Surg Oncol. 2000;73(4):192-197.
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Gradl G, Postl LK, Lenze U, et al. Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors. BMC Musculoskelet Disord. 2015;16:262.
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Krajbich JI. Rotation-plasty in the management of proximal femoral focal deficiency. Prosthet Orthot Int. 1991;15(2):100-107.
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Sawamura C, Hornicek FJ, Gebhardt MC. Complications and risk factors for failure of rotationplasty: review of 25 patients. Clin Orthop Relat Res. 2008;466(6):1302-1308.
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Kotz R, Salzer M. Rotation-plasty for childhood osteosarcoma of the distal part of the femur. J Bone Joint Surg Am. 1982;64(7):959-969.
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Merkel KD, Gebhardt MC, Springfield DS. Rotationplasty as a reconstructive operation after tumor resection. Clin Orthop Relat Res. 1991;(270):231-236.
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Hillmann A, Rosenbaum D, Gosheger G, et al. Rotationplasty type B1 versus type BIIIa. Gait Posture. 2001;14(1):51-59.