Outcomes of Rotationplasty Patients

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Functional Outcomes of Rotationplasty Patients in a Developed and Developing Country

Author: Kristoffer Roland U. Roa

Co-author: Noel Rex Penaranda, Nico Raga, Tsukasa Yonemoto, Shintaro Iwata

INTRODUCTION

The goal of orthopaedic surgeons for treating patients is to restore the physical function and improve the quality of life of patients with musculoskeletal disorders. Functional outcome after surgery varies despite the global success of various orthopedic procedures. Poor emotional health have been associated with poor functional outcomes.1,2

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Multiple studies have been published regarding functional outcomes of rotationplasty patients. 3,4,5,6,7,8,9,10,11,12,13 However, no study have been published comparing the functional outcome of rotationplasty patients between a developed and developing country. This is also the first study in the Philippines regarding functional outcomes of rotationplasty patients treated locally.

The purpose of this is study is to compare the functional outcome of patients from a developed and developing country after rotationplasty and to reiterate their usefulness in patients with musculoskeletal tumors around the knee.

The population of the Philippines has been progressively rising for many years. It is the 12th most populated country in the world and 7th most-populated in Asia with a growth rate of 1.9% per year, one of the highest in asia.14 It is the72th-largest countryin the world with approximately 300,000 square kilometers (115,831 sq mi)15 and is a considered a developing country with a low-middle income economy.16,17

Japan is a developed country and is one of Asia’s most successful democracies and largest economies. It is the 61st largest country in the world with approximately 127,380.00 people. It is ranked third in Asia on the Human Development Index.17,18 According to United Nations Development Programme (UNDP), Japan is among the top 20 (17th) with a very high human development index, compared with the Philippines, which is 117th in the world with medium human development index.19

Rotationplasty is a procedure wherein the distal femur and distal tibia are divided and the resected specimen removed. The foot is rotated 180 degrees on the neurovascular bundle and the tibia is reattached to the femur which results in a shortened limb with the ankle joint functioning as the knee joint.20,21

Expandable prosthesis or a rotationplasty are options for limb salvage options in young patients with musculoskeletal tumors around the knee.22,23,24 Rotationplasty is considered to be a good alternative to endoprosthetic replacement or above-the-knee amputation in patients with musculoskeletal tumor. This is an ideal procedure in developing countries such as the Philippines, since it is low cost and provides good functional outcome comparable with endprosthetic replacement.

The most number of cases of Rotationplasty done in the Philippines is in Southern Philippines Medical Center with 8 cases. An unpublished study was done by Raga et al. last 2010, describing the clinical profile and functional outcome of Osteosarcoma patients treated by rotationplasty surgery at SPMC which resulted in good functional outcomes. The purpose of the present study is to compare the clinical and functional outcome of Rotationplastysurgery patients treated in Southern Philippines Medical Center (Philippines) compared with Chiba Cancer Center (Japan).

Review of Related Literature

Rotationplasty procedure was first described by Borggreve in 1930 for the treatment of tuberculousankylosis of the knee joint.25 In 1950, Van Nes used the same technique for patients with congenital defects of the femur.26 Salzer and Knahrfirst adapted the technique in treating osteosarcoma in the distal part of the femur 1970sas an alternative to above-the-knee amputation.27 Since then, modified techniques have been developed for tumors affecting different levels on the limb, thus, rotationplasty has been an option for operative treatment of tumors.

Knee rotationplasty’s advantages over total knee arthroplasty are superior durability, easy correction of length differences between the limbs by prosthesis and less infection.Compared with above-the-knee amputation, it has better functions and the absence of phantom limb pain and possibility of body weight reliance on the heel makes it a more favorable option.28,29,30

Van Nes rotationplasty surgery has been questioned due to the high degree of deviation from what is considered normal anatomy.31,32,33,34 The appearance of the leg after rotationplasty which is unusual to most people may be a disadvantage.35 The patient’s or parent’s hesitation about having the foot on “backward” projects a mental image that may prevent proceeding with rotationplasty.

A study reported by Tebbi and Mallon showed that 40% of patients primarily reported body image and sexuality concerns after limb-shortening procedures; however, at final 10-year follow-up, patients reported living completely functional and fulfilling lives.36,37

In addition, the presence of the foot gives the patients the feeling of preserved integrity despite considerable limb shortening.38

A number of authors have highlighted the ability of children with rotationplasty to take part in vigorous physical activities and team sports and, broadly speaking, the limited functional data available would support the observation that people with rotationplasty are able to perform at a reasonably high level.39,40

Patients undergoing rotationplasty also avoid postoperative complications associated with above-knee amputations and endoprosthetic reconstructive procedures, including phantom pain, neuroma formation, postoperative stiffness, bone overgrowth, and infection.41 Numerous studies have reported excellent outcomes following rotationplasty with regard to return to activities of daily living, function, and sports.42,43

After wearing the prosthesis, patients retain an actively controlled knee joint as the foot is able to carry the load that is transferred to both plantar and dorsal aspects of the foot. These patients achieve a high level of activity in daily life and sports. Several studies reported good functional results in Rotationplasty.44,45,46,47,48,49 Due to the advancement of adjuvant chemotherapy, imaging and surgical techniques. Improvement of the survival rate and functional outcomes of patients with musculoskeletal tumors were possible.

Research Questions

  1. What are the clinical profiles of patients treated with rotationplasty in Chiba Cancer Center (Japan) and Southern Philippines Medical Center (Davao City)?
  2. What are the functional outcomes of patients with musculoskeletal tumors around the knee treated by Rotationplasty surgery in Southern Philippines Medical Center (Philippines) and in Chiba Cancer Center (Japan)?

Significance of the Study

Megaprostheses are commonly used for limb salvage surgeries in patients with musculoskeletal tumors around the knee. However, they are quite expensive and are not locally available. In our setting where most of our patients are poor with very limited resources, Rotationplasty is a reasonable alternative for limb salvage surgery. This study evaluated the clinical profile and functional outcomes of patients with musculoskeletal tumor around the knee treated with Rotationplasty surgery in Southern Philippines Medical Center (Philippines) and in Chiba Cancer Center (Japan).

Objectives of the Study:

General Objective

This study aims to compare the functional outcome of patients who underwent rotationplasty surgery in a developing country, SPMC (Philippines), compared with a developed country, Chiba Cancer Center (Japan).

Specific Objectives

Specifically, the study aims to:

  1. To determine the clinical profiles of patients.
  2. To compare the patients’ functional outcome of post-rotationplasty surgery done in SPMC (Philippines) and in Chiba Cancer Center (Japan).

METHODOLOGY

Research Design: Ambispective cohort study.

Setting

9 patients with a malignant tumor around the knee were treated with rotationplasty in Southern Philippines Medical Center. The patients will be asked to fill out the MSTSS (Musculoskeletal Tumor Society Rating Scale). The anwers of each patients will be tallied, processed, and analyzed.

The data of obtained will be used to compare the clinical and functional outcome of rotationplasty surgery patients in Chiba Cancer Center (Japan).

Participants

  1. Inclusion Criteria
  1. All patients who with malignant tumors around the knee and was treated with rotationplasty surgery.
  1. Exclusion Criteria
    1. Patients with malignant tumors around the knee treated with other methods aside from rotationplasty.
    2. Patients who have no consent and expired since the start of the study.

Data Gathering

Data will be collected from the patients treated with rotationplasty in this institution. After which, we will conduct a simultaneous research question with the researchers in Chiba Cancer Center (Japan) which is translated in Japanese.

This is our measurement tool:

  1. Musculoskeletal Tumor Society Score (MSTSS)

Function was assessed with the Musculoskeletal Tumor Society Score, made by Musculoskeletal Tumor Society to evaluate functional outcome patients after limb salvage procedures.50 It is a subjective assessment by the patient composed of six parameters : pain, function, emotional acceptance, use of walking supports, walking ability, and gait. Each parameter was assigned a value ranging from 0 to 5 and will be added together with a maximum of 30 points.51,52,53,54,55,56,57

The patients filled up the English or tagalong (bisaya) MSTSS questionnaire.

Sample Size Calculation

This is a comparative study of Rotationplasty surgery on patients with musculoskeletal tumor around the knee in Southern Philippines Medical Center (Philippines) and Chiba Cancer Center (Japan).

Data Handling and Analysis

The data from the interviewed patients will be reviewed. The functional outcome using MSTSS (Muscoloskeletal Tumor Society Rating Scale) will be described, summarized and processed.

Dummy Tables:

Table I. Clinical characteristics of patients.

 

Southern Philippines Medical Center

Chiba Cancer Center

Gender

Male: __, Female: __

Male: __, Female: __

Age at the time of survey

__ to __ (mean: __)

__ to __ (mean: __)

Primary site

Femur: __, Tibia __

Femur: __, Tibia __

Metastasis

   
     

Table 2. Musculoskeletal Tumor Society Score

Patient

1

2

3

4

5

6

7

Pain

             

Function

             

Emotional

             

Support

             

Gait

             

Walking

             

Total

             

Mean Point :

Percentage :

Functional Outcomes of Rotationplasty Patients in a Developed and Developing Country

Author: Kristoffer Roland U. Roa

Co-author: Noel Rex Penaranda, Nico Raga, Tsukasa Yonemoto, Shintaro Iwata

INTRODUCTION

The goal of orthopaedic surgeons for treating patients is to restore the physical function and improve the quality of life of patients with musculoskeletal disorders. Functional outcome after surgery varies despite the global success of various orthopedic procedures. Poor emotional health have been associated with poor functional outcomes.1,2

Multiple studies have been published regarding functional outcomes of rotationplasty patients. 3,4,5,6,7,8,9,10,11,12,13 However, no study have been published comparing the functional outcome of rotationplasty patients between a developed and developing country. This is also the first study in the Philippines regarding functional outcomes of rotationplasty patients treated locally.

The purpose of this is study is to compare the functional outcome of patients from a developed and developing country after rotationplasty and to reiterate their usefulness in patients with musculoskeletal tumors around the knee.

The population of the Philippines has been progressively rising for many years. It is the 12th most populated country in the world and 7th most-populated in Asia with a growth rate of 1.9% per year, one of the highest in asia.14 It is the72th-largest countryin the world with approximately 300,000 square kilometers (115,831 sq mi)15 and is a considered a developing country with a low-middle income economy.16,17

Japan is a developed country and is one of Asia’s most successful democracies and largest economies. It is the 61st largest country in the world with approximately 127,380.00 people. It is ranked third in Asia on the Human Development Index.17,18 According to United Nations Development Programme (UNDP), Japan is among the top 20 (17th) with a very high human development index, compared with the Philippines, which is 117th in the world with medium human development index.19

Rotationplasty is a procedure wherein the distal femur and distal tibia are divided and the resected specimen removed. The foot is rotated 180 degrees on the neurovascular bundle and the tibia is reattached to the femur which results in a shortened limb with the ankle joint functioning as the knee joint.20,21

Expandable prosthesis or a rotationplasty are options for limb salvage options in young patients with musculoskeletal tumors around the knee.22,23,24 Rotationplasty is considered to be a good alternative to endoprosthetic replacement or above-the-knee amputation in patients with musculoskeletal tumor. This is an ideal procedure in developing countries such as the Philippines, since it is low cost and provides good functional outcome comparable with endprosthetic replacement.

The most number of cases of Rotationplasty done in the Philippines is in Southern Philippines Medical Center with 8 cases. An unpublished study was done by Raga et al. last 2010, describing the clinical profile and functional outcome of Osteosarcoma patients treated by rotationplasty surgery at SPMC which resulted in good functional outcomes. The purpose of the present study is to compare the clinical and functional outcome of Rotationplastysurgery patients treated in Southern Philippines Medical Center (Philippines) compared with Chiba Cancer Center (Japan).

Review of Related Literature

Rotationplasty procedure was first described by Borggreve in 1930 for the treatment of tuberculousankylosis of the knee joint.25 In 1950, Van Nes used the same technique for patients with congenital defects of the femur.26 Salzer and Knahrfirst adapted the technique in treating osteosarcoma in the distal part of the femur 1970sas an alternative to above-the-knee amputation.27 Since then, modified techniques have been developed for tumors affecting different levels on the limb, thus, rotationplasty has been an option for operative treatment of tumors.

Knee rotationplasty’s advantages over total knee arthroplasty are superior durability, easy correction of length differences between the limbs by prosthesis and less infection.Compared with above-the-knee amputation, it has better functions and the absence of phantom limb pain and possibility of body weight reliance on the heel makes it a more favorable option.28,29,30

Van Nes rotationplasty surgery has been questioned due to the high degree of deviation from what is considered normal anatomy.31,32,33,34 The appearance of the leg after rotationplasty which is unusual to most people may be a disadvantage.35 The patient’s or parent’s hesitation about having the foot on “backward” projects a mental image that may prevent proceeding with rotationplasty.

A study reported by Tebbi and Mallon showed that 40% of patients primarily reported body image and sexuality concerns after limb-shortening procedures; however, at final 10-year follow-up, patients reported living completely functional and fulfilling lives.36,37

In addition, the presence of the foot gives the patients the feeling of preserved integrity despite considerable limb shortening.38

A number of authors have highlighted the ability of children with rotationplasty to take part in vigorous physical activities and team sports and, broadly speaking, the limited functional data available would support the observation that people with rotationplasty are able to perform at a reasonably high level.39,40

Patients undergoing rotationplasty also avoid postoperative complications associated with above-knee amputations and endoprosthetic reconstructive procedures, including phantom pain, neuroma formation, postoperative stiffness, bone overgrowth, and infection.41 Numerous studies have reported excellent outcomes following rotationplasty with regard to return to activities of daily living, function, and sports.42,43

After wearing the prosthesis, patients retain an actively controlled knee joint as the foot is able to carry the load that is transferred to both plantar and dorsal aspects of the foot. These patients achieve a high level of activity in daily life and sports. Several studies reported good functional results in Rotationplasty.44,45,46,47,48,49 Due to the advancement of adjuvant chemotherapy, imaging and surgical techniques. Improvement of the survival rate and functional outcomes of patients with musculoskeletal tumors were possible.

Research Questions

  1. What are the clinical profiles of patients treated with rotationplasty in Chiba Cancer Center (Japan) and Southern Philippines Medical Center (Davao City)?
  2. What are the functional outcomes of patients with musculoskeletal tumors around the knee treated by Rotationplasty surgery in Southern Philippines Medical Center (Philippines) and in Chiba Cancer Center (Japan)?

Significance of the Study

Megaprostheses are commonly used for limb salvage surgeries in patients with musculoskeletal tumors around the knee. However, they are quite expensive and are not locally available. In our setting where most of our patients are poor with very limited resources, Rotationplasty is a reasonable alternative for limb salvage surgery. This study evaluated the clinical profile and functional outcomes of patients with musculoskeletal tumor around the knee treated with Rotationplasty surgery in Southern Philippines Medical Center (Philippines) and in Chiba Cancer Center (Japan).

Objectives of the Study:

General Objective

This study aims to compare the functional outcome of patients who underwent rotationplasty surgery in a developing country, SPMC (Philippines), compared with a developed country, Chiba Cancer Center (Japan).

Specific Objectives

Specifically, the study aims to:

  1. To determine the clinical profiles of patients.
  2. To compare the patients’ functional outcome of post-rotationplasty surgery done in SPMC (Philippines) and in Chiba Cancer Center (Japan).

METHODOLOGY

Research Design: Ambispective cohort study.

Setting

9 patients with a malignant tumor around the knee were treated with rotationplasty in Southern Philippines Medical Center. The patients will be asked to fill out the MSTSS (Musculoskeletal Tumor Society Rating Scale). The anwers of each patients will be tallied, processed, and analyzed.

The data of obtained will be used to compare the clinical and functional outcome of rotationplasty surgery patients in Chiba Cancer Center (Japan).

Participants

  1. Inclusion Criteria
  1. All patients who with malignant tumors around the knee and was treated with rotationplasty surgery.
  1. Exclusion Criteria
    1. Patients with malignant tumors around the knee treated with other methods aside from rotationplasty.
    2. Patients who have no consent and expired since the start of the study.

Data Gathering

Data will be collected from the patients treated with rotationplasty in this institution. After which, we will conduct a simultaneous research question with the researchers in Chiba Cancer Center (Japan) which is translated in Japanese.

This is our measurement tool:

  1. Musculoskeletal Tumor Society Score (MSTSS)

Function was assessed with the Musculoskeletal Tumor Society Score, made by Musculoskeletal Tumor Society to evaluate functional outcome patients after limb salvage procedures.50 It is a subjective assessment by the patient composed of six parameters : pain, function, emotional acceptance, use of walking supports, walking ability, and gait. Each parameter was assigned a value ranging from 0 to 5 and will be added together with a maximum of 30 points.51,52,53,54,55,56,57

The patients filled up the English or tagalong (bisaya) MSTSS questionnaire.

Sample Size Calculation

This is a comparative study of Rotationplasty surgery on patients with musculoskeletal tumor around the knee in Southern Philippines Medical Center (Philippines) and Chiba Cancer Center (Japan).

Data Handling and Analysis

The data from the interviewed patients will be reviewed. The functional outcome using MSTSS (Muscoloskeletal Tumor Society Rating Scale) will be described, summarized and processed.

Dummy Tables:

Table I. Clinical characteristics of patients.

 

Southern Philippines Medical Center

Chiba Cancer Center

Gender

Male: __, Female: __

Male: __, Female: __

Age at the time of survey

__ to __ (mean: __)

__ to __ (mean: __)

Primary site

Femur: __, Tibia __

Femur: __, Tibia __

Metastasis

   
     

Table 2. Musculoskeletal Tumor Society Score

Patient

1

2

3

4

5

6

7

Pain

             

Function

             

Emotional

             

Support

             

Gait

             

Walking

             

Total

             

Mean Point :

Percentage :

References:

  1. Ayers DC, Franklin PD, Trief PM, Ploutz-Snyder R, Freund D. Psychological attributes of preoperative total joint replacement patients: Implications for optimal physical outcome. J Arthroplasty. 2004 Oct; 19(7)(Suppl 2):125-30.
  2. Ayers DC, Franklin PD, Ploutz-Snyder R, Bolsvert CB. Total knee replacement outcome and coexisting physical and emotional illness. Clin Orthop Relat. Res. 2005 Nov;(440):157-61.
  3. Mclenaghan BA, et al., J Bone Joint Surg Am, 1989. 71(8):1178-82.
  4. Cammisa FP, et al., J Bone Joint Surg AM, 1990. 72(10):1541-7.
  5. Steenhoff JR, et al., J Bone Joint Surg Am, 1993. 75(10):1451-6.
  6. Hillmann A, et al., J Bone Joint Surg Am, 2000. 82(2):187-96.
  7. Wicart P, et al., J Bone Joint Surg Br, 2002. 8):864(65-9.
  8. Fuchs B, et al., Clin Orthop Rel Res, 2003. 415:52-8.
  9. Hillmann A, et al., J Bone Joint Surg Am, 1999. 81(4):462-8.
  10. Hopyan S, et al., J Ped Orthop, 2006. 26(3):405-8.
  11. Badhwar R and Agarwal M, Int Orthop, 1998. 22(2):122-5.
  12. Hillmann A, et al., Clin Orthop, 2001. 384:224-31.
  13. Hillmann A., et al., Arch Orthop Trauma Surg, 2000. 120(10):555-8.)
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  20. Bari, A. Krajbich, J.I., Langer, F., Hamilton, E.L., Hubbard, Sheila (1990) Modified Van NesRotationplasty for Osteosarcoma of the Proximal Tibia in Children, Vol. 72-B, No. 6, pp. 1067.
  21. Kotz, R.: Rotationplasty. Sem. Surg. Oncol., 13: 34-40, 1997.
  22. Lewis MM. The Use of an Expandable and Adjustable Prosthesis in the Treatment of Childhood Malignant Bone Tumors of the Extremity. Cancer 1986;57:499.
  23. Tillman RM, Grimer RJ, Carter SR, et al. Growing Endoprostheses for Primary Malignant Bone Tumors. SeminSurgOncol 1997;13:41.
  24. Winkelman WW. Rotationplasty. OrthopClin North Am 1996;27:503.
  25. Kotz, R.: Rotationplasty. Sem. Surg. Oncol., 13: 34-40, 1997.
  26. Van Nes, C. P.: Rotation-plasty for congenital defects of the femur. Making use of the ankle of the shortened limb to control the knee joint of a prosthesis. J. Bone and Joint Surg., 32-B (1): 12-16, 1950.
  27. Salzer, M., and Knahr, K.: Die operative Therapie der malignenKnochentumoren. Zeitschr. Orthop., 116: 517-525, 1978.
  28. Gottsauner-Wolf F, Kotz R, Knahr K, et al: Rotationplasty for limb salvage in the treatment of malignant tumor at the knee. J Bone Joint Surg Am 73: 1365-1375, 1991.
  29. Murray MP, Jacobs PA, Gore DR, et al: Functional performance after tibialrotationplasty. J Bone Joint Surg Am 67: 392-399, 1985.
  30. Catani F, Capanna R, Benedetti MG, et al: Gait analysis in patients after Van Nesrotationplasty. ClinOrthop 296: 270-277, 1993.
  31. Betsy M, Capozzi JD, Rhodes R. The human form: accepting the prioritization of patient values. J Bone Joint Surg Am. 2005;87(7):1653-1655.
  32. Gottsauner-Wolf F, Kotz R, Knahr K, Kristen H, Ritschl P, Salzer M. Rotationplasty for limb salvage in the treatment of malignant tumors at the knee. A follow-up study of sev­enty patients. J Bone Joint Surg Am. 1991; 73(9):1365-1375.
  33. 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.
  34. Gebert C, Hardes J, Vieth V, Hillmann A, Winkelmann W, Gosheger G. The effect of rotationplasty on the ankle joint: long-term results. Prosthet Orthot Int. 2006; 30(3):316-323.)
  35. Hillmann A, Hoffmann C, Gosheger G, et al: Malignant tumor of the distal part of the femur or the proximal part of the tibia: Endoprosthetic replacement or rotationplasty. J Bone Joint Surg Am 81: 462-468, 1999.
  36. Tebbi CK, Mallon JC. Long-term psychosocial outcome among cancer amputees in adolescence and early adulthood. J Psychosoc Oncol. 1988; 5(4):69-82.) The appearance was not observed to be a problem.
  37. Alman BA, et al., J Bone Joint Surg Am, 1995. 77(12):1876-82.
  38. Friscia DA, Moseley CF, Oppenheim WL. Rotational osteotomy for proximal femoral focal deficiency. J Bone Joint Surg Am. 1989; 71(9):1386-1392.)
  39. Cammisa FP, et al., J Bone Joint Surg Am, 1990. 72(10):1541-7.
  40. Krajbich JI, Clin Orthop Rel Res, 1991. 262:74-7.) (Kotz R and Salzer M., J Bone Joint Surg, 1982. 64(7):659-69.
  41. Murray MP, Jacobs PA, Gore DR, et al: Functional performance after tibialrotationplasty. J Bone Joint Surg Am 67: 392-399, 1985
  42. Hillmann A, Hoffmann C, Gosheger G, et al: Malignant tumor of the distal part of the femur or the proximal part of the tibia: Endoprosthetic replacement or rotationplasty. J Bone Joint Surg Am 81: 462-468, 1999.
  43. Sugarbaker, P.H.; Barofsky, I.; Rosenberg, S.A.; and Gianola, F.J.: Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery, 91; 17-23, 1982.
  44. Cammisa, F. P., Jr.; Glasser, D. B.; Otis, J. C.; Kroll, M. A.; Lane, J. M.; and Healey, J. H.: The Van Nes tibial rotationplasty. A functionally viable reconstructive procedure in children who have a tumor of the distal end of the femur. J. Bone and Joint Surg., 72A: 1541-1547, Dec. 1990.
  45. Finn, H. A., and Simon, M. A.: Limb-salvage surgery in the treatment of osteosarcoma in skeletally immature individuals. Clin. Orthop., 262: 108-118, 1991.
  46. Kotz, R., and Salzer, M.: Rotation-plasty for childhood osteosarcoma of the distal part of the femur. J. Bone and Joint Surg., 64-A: 959-969, Sept. 1982.
  47. Murray, M. P.; Jacobs, P. A.; Gore, D. R.; Gardner, G. M.; and Mollinger, L. A.: Functional performance after tibialrotationplasty. J. Bone and Joint Surg., 67-A: 392-399, March 1985.
  48. Steenhoff, J. R. M.; Daanen, H. A. M.; and Taminiau, A. H. M.: Functional analysis of patients who have had a modified Van Nesrotationplasty. J. Bone and Joint Surg., 75-A: 1451-1456, Oct. 1993.
  49. Winkelmann, W. W.: Hip rotationplasty for malignant tumors of the proximal part of the femur. J. Bone and Joint Surg., 68-A: 362-369, March 1986.
  50. Sim FH, Frassica FJ, Miser JS, Unni KK. Current Concepts in the Evaluation and Treatment of Osteosarcoma of Bone. Adv Operative Orthop 1993;1:345.
  51. Hillmann A, et al., J Bone Joint Surg Am, 2000. 82(2):187-96.) (Wicart P, et al., J Bone Joint Surg Br, 2002. 8):864(65-9.
  52. Fuchs B, et al., Clin Orthop Rel Res, 2003. 415:52-8.
  53. Hillmann A, et al., J Bone Joint Surg Am, 1999. 81(4):462-8.
  54. Hopyan S, et al., J Ped Orthop, 2006. 26(3):405-8.
  55. Badhwar R and Agarwal M, Int Orthop, 1998. 22(2):122-5.
  56. Hillmann A, et al., Clin Orthop, 2001. 384:224-31.
  57. Hillmann A., et al., Arch Orthop Trauma Surg, 2000. 120(10):555-8.)

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