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Introduction

The first use of rotationplasty was documented by Borggreve (1) in 1930 and it was applied to treat lower limb shortening caused by knee joint tuberculosis infection. In 1975, Kristen et al (2) applied rotationplasty to treat the recurrence of osteosarcoma in the distal femur. Rotationplasty is a limb salvage surgery that provides a postoperative function similar to that of below-knee amputation. The type of rotationplasty is dependent on the initial reconstruction of the distal femur (type AI), the proximal tibia (type AII) or the proximal femur involving the acetabulum (type BII) (3). During this surgical procedure, the tumor is excised in its entirety, while preserving the neurovascular bundle, the distal portion of the tibia and the foot. The tibia and foot are then rotated by 180° to attach on backwards to the limb salvage portion of the distal femur. It has been reported that this method can help in avoiding complications, such as phantom pain, and reduce infection rates. Following surgery, the rotated ankle joint can function as a knee joint with the assistance of special prostheses (4).

Pediatric and adolescent patients are at a high risk of developing malignant bone tumors, including osteosarcoma and Ewing's sarcoma. Amputation has conventionally been considered as a prevailing approach for managing these types of tumors. However, the 5-year survival rates fall short of the desired outcomes (5). Nevertheless, the advent of more sophisticated surgical techniques and the utilization of neoadjuvant chemotherapy has led to a notable increase in the 5-year survival rate of patients, which currently stands at ~70% worldwide (6). Furthermore, the importance of functional recovery following surgery has become more pronounced. Previous studies indicated that patients who underwent rotationplasty tended to achieve better functional outcomes compared with those who were subjected to knee amputation or endoprosthesis replacement (7,8). Benedetti et al (9) emphasized the importance of rehabilitation following rotationplasty for improving postoperative functional outcomes. Morri and Forni (10) outlined the rehabilitation methods and expected outcomes of an adult patient who underwent rotationplasty and showed a favorable outcome. In recent years, there has been a growing interest in functional rehabilitation following rotationplasty. However, there is a clear need for the development of standardized and effective rehabilitation guidance. Therefore, the present study aimed to develop a series of rehabilitation strategies for functional recovery at distinct stages of the postoperative period. These strategies were then longitudinally evaluated to assess functional recovery rates and the quality of life of patients. The findings of the current study could serve as a reference for patients seeking to efficiently recover function.

Materials and methods

Participants

A total of 12 patients, including 7 males (58%) and 5 females (42%), with a mean age at surgery of 6.58±1.73 years (range, 4–10 years), who were admitted to the Fourth Medical Center of Chinese People's Liberation Army (PLA) General Hospital (Beijing, China) between March 2014 and March 2019, were included. The disease duration from onset to consultation was 3–5 months (mean, 4.50±0.67 months). All patients are still alive today, with a follow-up period of 60–120 months (mean, 89.83±17.55 months). In terms of pathological subtypes, 4 patients suffered from osteoblastic osteosarcoma (33%), 2 from chondroblastic osteosarcoma (17%), 3 from mixed osteosarcoma (25%) and 3 from Ewing's sarcoma (25%). The inclusion criteria were as follows: i) Peripheral malignant bone tumor of the knee joint confirmed by preoperative biopsy and postoperative pathology; ii) Enneking stage IIB disease (11), with AI-type rotationplasty (3) performed; iii) postoperative rehabilitation for 6 months; and iv) a follow-up period of ≥5 years. Patients with multiple tumors or metastases and those who refused to participate in the study were excluded. The present retrospective study was approved by the Institutional Review Board of the Fourth Medical Center of the Chinese PLA General Hospital (approval no. 2023KY037-KS001). All patients and their duly authorized representatives provided written informed consent for the study to be published. All methods were performed according to the relevant guidelines and regulations.

Surgery and treatment

All patients underwent 7–9 cycles of pre- and post-operative chemotherapy following the protocol of the Fourth Medical Center of the Chinese PLA General Hospital (12). This regimen included ifosfamide (2 g/m2 on days 1–5), methotrexate (8 g/m2 on day 3) and doxorubicin (100 mg/m2 on day 5). A typical preoperative chemotherapy regimen comprised three courses, whereas the postoperative regimen consisted of six courses. Each course had a duration of 5 days, with a 3-week interval between courses. Prior and during chemotherapy, both hydration and alkalization were employed, involving a daily fluid intake exceeding 3,000 ml. Additionally, urine volume and pH were closely monitored to sustain a urine pH level of between 7 and 8. In cases where the patient exhibited a white blood cell count of <2.0×109/l, a daily subcutaneous injection of 300 µg granulocyte colony-stimulating factor was administered. All patients were informed of the potential risks associated with the treatment and provided written informed consent. The rotationplasty was performed under general anesthesia. The pre- and 1-year post-surgery X-rays of a representative patient who underwent rotationplasty are shown in Fig. 1. The surgical procedure is displayed in Fig. 2. Following surgery, the patients were required to undergo a 6-month program of postoperative rehabilitation, either as outpatients or in the hospital. This program involved one session per day, for 50 min, and five sessions per week. Upon discharge, the patients continued to receive symptomatic treatment and were scheduled for regular follow-up appointments. These were conducted at 3-monthly intervals during the 5-year postoperative period, and annually thereafter.

Figure 1. X-ray images of a representative patient included in the study. (A) Pre-rotationplasty (arrow indicating the tumor). (B) At 1 year post-rotationplasty.

Figure 2. Surgical procedure applied in a representative patient with a bone tumor. (A) The bone tumor was resected while preserving the neurovascular bundle to preserve the viability of the foot. (B) Following rotationplasty, the foot was restored, and the ankle joint could act as a substitute knee joint.

Rehabilitation strategies

In the initial phase, spanning from the first to third week following surgery, patients underwent immediate rehabilitation treatment. The objectives of this stage were to facilitate wound healing, prevent deep vein thrombosis in the lower limbs and restore joint mobility, in preparation for prosthesis fitting. The particular training approach included isometric contractions of the gluteal and anterior muscles on the affected side, as well as active and passive dorsiflexion and plantarflexion exercises of the knee (ankle) joint on the affected side. The exercises were carried out under pain-free conditions. The patient was instructed to perform isometric contractions of the gluteal and anterior muscles in the supine position. Each contraction lasted for 5–10 sec, with a 3-sec rest interval between each one. A total of three sets of 20 repetitions were completed, with a 1-min rest between each set. In terms of knee (ankle) joint mobility training, each repetition consisted of a single cycle of 3 sec of dorsiflexion and plantarflexion, with a 1-sec rest interval between each cycle. A total of three sets of 20 repetitions were completed, with a 1-min rest between each set.

In the second stage, 4 weeks to 3 months after surgery, the objective was to enhance the muscle strength, balance and coordination of the patient. The training regimen included progressive resistance training of the anterior muscle group and weight-shifting exercises. During progressive resistance training of the affected lower limb, the patient was placed in a supine position on the bed, actively lifting the affected leg to a position 30° above the bed surface. The therapist applied appropriate resistance at the end of the affected limb, holding the position for 5–10 sec, with a 3-sec rest between each repetition. A total of three sets of 10 repetitions were completed, with a 1-min rest between each set. The patient used an assistive device to facilitate standing and perform weight-shifting training. In addition, the patient was instructed to maintain a shoulder-width stance with eyes fixed straight ahead. Each patient was then asked to shift their weight to the healthy side, followed by the affected side, while ensuring that they remained pain-free. During the training session, the patient had to maintain an upright upper body position, thus preventing lateral bending of the trunk and heel lift. A total of three sets of 40 repetitions were completed, with a 1-min rest interval between each set.

In the third stage, which lasted from the fourth to the sixth month following surgery, the patients underwent additional gait and stair climbing training, based on the second stage training, to restore the basic lower limb function, which was required for daily activities. The gait training program included the stance phase, the swing phase and the simulation of daily life scenarios. The stance phase training progressed from bilateral hand support with handrails to single hand support on the unaffected side and subsequently to a no support state. The swing phase of gait training was primarily associated with the experience of changes in body weight during walking. The training program included simulated daily life scenarios, including uphill and downhill training. Additionally, the patient utilized a stair-climbing trainer for ascending and descending stairs. Prior to commencing the training program, the stair handrails were adjusted to a height that was suitable for the patient. Furthermore, the principle of stepping up with the unaffected limb first and then stepping down with the affected limb was applied.

Evaluation indicators

To assess the range of motion (ROM) of the knee (ankle) joint, the patient was instructed to assume a supine position and then flex and extend the knee (ankle) joint as far as possible to the maximum angle. The ROM of the knee (ankle) joint was then measured with a manual articular goniometer (13).

The maximal strength of the anterior muscle groups was quantified using the manual muscle test. For this, the patients were seated and instructed to extend the knee (ankle) joint, either with or without gravity, or against an increasing resistance force applied by a physiotherapist. A scale ranging from 0 (no muscular contraction) to 5 (full range of motion against manually applied resistance force) was employed to assess the level of muscular contraction (14).

Furthermore, the Musculoskeletal Tumor Society scoring system, including six distinct parameters, was employed to assess patient outcomes. These parameters included limb pain, active function, psychological endurance, bracing, walking and gait. Each parameter was graded on a scale of 0–5 points, with higher scores indicating better limb recovery (15). In addition, to evaluate the degree of autonomy acquired and perceived in daily life, the Toronto Extremity Salvage Score was employed. The score comprises 30 items, with each parameter rated on a scale ranging from 0 to 5 points. A higher score indicates a greater level of autonomy (16).

The 6-min walk test was applied to assess walking endurance. Patients were requested to walk as far as possible at their preferred speed for 6 min, and the walking distance was then recorded and measured (17). Motor performance was evaluated using the timed up and go test, which records the time taken for the patient to stand up, walk for 3 meters, turn around, return to the starting position and sit down again (18).

Finally, the quality of life was evaluated utilizing the 36-item Short Form Health Survey score, which incorporates the following eight distinct parameters: Physical functioning, role-physical (RP), bodily pain, general health, vitality, social functioning, role-emotional and mental health. The assessment yielded scores for the physical and mental functions of the patients, with a higher score indicating superior overall health and quality of life (19).

Literature search and selection

A systematic search of the Medline (https://medline.nlm.nih.gov/), Scopus (http://www.scopus.com/), Embase (https://www.embase.com/) and Cochrane (https://www.cochranelibrary.com/) databases was conducted until 31 March, 2024, to identify eligible studies. The objective was to ascertain the functional rehabilitation outcomes associated with rotationplasty. The search algorithm comprised the following terms: ‘rehabilitation’, ‘quality of life’, ‘malignant bone tumors’, ‘limb salvage’ and ‘rotationplasty’. The titles and abstracts of articles were screened by two independent investigators, and potentially eligible reports were sought for retrieval and full-text assessment. In the event of a discrepancy between the two investigators regarding eligibility, a third investigator would be consulted to evaluate the article in question. The inclusion criteria comprised patients who had undergone rotationplasty subsequent to the resection of a lower limb tumor and those who had undergone an evaluation of functional or quality of life. Conversely, articles were excluded if lower limb tumors were not cited as the indication for rotationplasty, if studies did not present findings from assessments of functional or quality of life, and if they were in languages other than English.

Statistical analysis

The statistical analysis was conducted using IBM SPSS Statistics v.21 (IBM Corp.). The numerical data are expressed as the mean ± standard deviation, while categorical data are expressed as proportions or percentages. To assess the linear trend relationship between time variables and functional outcomes and quality of life, a P-value was utilized. Parametric data were analyzed using repeated measures ANOVA to assess differences among multiple groups. In the event of a significant difference between groups, pairwise comparisons were conducted using Bonferroni's post hoc test. Non-parametric data were evaluated across groups using the Friedman test, and in case of significant differences, pairwise comparisons were performed using Nemenyi's post hoc test. P<0.05 was considered to indicate a statistically significant difference.

Results

The baseline data and clinical characteristics of the patients included in the present study are listed in Table I. All patients underwent rotationplasty due to tumor pathology. The extent of resection of the limb segment that contained the tumor ranged from 12 to 20 cm (mean, 16.5±2.32 cm), with the knee (ankle) joint extension length ranging from 3–8 cm (mean, 4.92±1.62 cm). The follow-up period ranged from 60–120 months (mean, 89.83±17.55 months). A patient with a case of non-union (8%) showed healing after 1 month of dressing changes. Another 2 cases of calluses and ulceration (17%) exhibited improvement after 1 month of physiotherapy and prosthetic adjustments. Figs. 3 and 4 depict the postoperative functional recovery and quality of life of the patients. At 1 year post-surgery, there was a significant improvement in limb function and quality of life (P<0.05), which remained stable thereafter (Tables II and III). Post hoc testing revealed no statistically significant differences in limb function and quality of life between the groups at 12 months, 3 years and 5 years postoperatively. A comparative analysis of several literature sources indicated that rehabilitation could play an important role in the functional recovery and quality of life of patients following rotationplasty (Tables IV and V). The results of the present study also demonstrated that the functional outcomes of patients at 1 year post-surgery were superior to those reported in previous studies, particularly in terms of knee (ankle) joint mobility and muscle strength recovery. At 1-year postoperatively, the mean score for each indicator of the quality-of-life scores of the patients was 91, representing a greater improvement than the 78 reported in the literature during the same period. Furthermore, the patients' PF scores at 1-year postoperatively were higher than those in all other studies.

Figure 3. Functional recovery 5 years after rotationplasty in 12 patients. (A) Knee (ankle) joint extension vs. time. (B) Knee (ankle) joint flexion vs. time. (C) Muscle strength vs. time. (D) MSTS vs. time. (E) TESS vs. time. (F) 6mWT vs. time. (G) TUG vs. time. *P<0.05 compared with baseline. MSTS, Musculoskeletal Tumor Society; TESS, Toronto Extremity Salvage Score; 6mWT, 6-min walk test; TUG, timed up and go.

Figure 4. SF-36 5 years after rotationplasty in 12 patients. (A) PF vs. time. (B) RP vs. time. (C) BP vs. time. (D) GH vs. time. (E) VT vs. time. (F) SF vs. time. (G) RE vs. time. (H) MH vs. time. *P<0.05 compared with baseline. SF-36, Short Form-36; PF, physical functioning; RP, role-physical; BP, bodily pain; GH, general health; VT, vitality; SF, social functioning; RE, role-emotional; MH, mental health.

Table I. Demographic characteristics of participants (n=12).

Table I.

Demographic characteristics of participants (n=12).

Characteristic	Value
Age, yearsa	6.58±1.73
Sex, n (%)
Male	7 (58.33)
Female	5 (41.67)
Course of disease, monthsa	4.50±0.67
Pathology, n (%)
Osteoblastic osteosarcoma	4 (33.33)
Chondroblastic osteosarcoma	2 (16.67)
Mixed osteosarcoma	3 (25.00)
Ewing's sarcoma	3 (25.00)
Length of tumor resection, cma	16.5±2.32
Extension length of knee (ankle) joint, cma	4.92±1.62
Follow-up time, monthsa	89.83±17.55
Complications, n (%)
Unhealed wound	1 (8.33)
Calluses and ulceration	2 (16.67)

a Data are presented as the mean ± SD.

Table II. Functional outcomes of patients after rotationplasty.

Table II.

Functional outcomes of patients after rotationplasty.

	Follow-up time post-surgery							95% Confidence interval
Functional indicators	3 months	6 months	12 months	3 years	5 years	F-value	P-value	Minimum	Maximum
Knee (ankle) joint extension, °	10.83 (3.95)	5.83 (4.17)	0.00 (0.00)	0.00 (0.00)	0.00 (0.00)	71.53	<0.001	−0.16	−0.10
Knee (ankle) joint Flexion, °	80.42 (5.42)	90.42 (3.96)	94.17 (1.95)	94.17 (1.95)	94.17 (1.95)	62.65	<0.001	0.07	0.12
Muscle strength (0–5)	3.58 (0.51)	4.67 (0.49)	5.00 (0.00)	5.00 (0.00)	5.00 (0.00)	38.91	<0.001	4.17	4.67
MSTS score	19.75 (2.01)	23.08 (1.24)	25.08 (1.68)	24.17 (1.40)	24.33 (1.44)	60.67	<0.001	0.18	0.30
TESS score	82.25 (2.09)	90.17 (1.47)	93.83 (1.34)	93.58 (1.68)	93.92 (1.56)	214.33	<0.001	0.13	0.17
6mWT, meters	192.92 (14.68)	370.08 (15.97)	403.08 (12.52)	403.75 (13.44)	403.50 (13.31)	733.28	<0.001	290.01	354.05
TUG, sec	20.33 (1.67)	11.33 (2.02)	8.83 (0.72)	8.92 (0.79)	8.75 (0.75)	178.85	<0.001	11.73	15.27

[i] Data are presented as mean (SD). MSTS, Musculoskeletal Tumor Society; TESS, Toronto Extremity Salvage Score; 6mWT, 6-min walking test; TUG, timed up and go.

Table III. Quality of life of patients after rotationplasty.

Table III.

Quality of life of patients after rotationplasty.

	Follow-up time post-surgery							95% Confidence interval
SF-36	3 months	6 months	12 months	3 years	5 years	F-value	P-value	Minimum	Maximum
Physical health
PF	54.58 (3.96)	71.67 (7.78)	89.58 (3.96)	89.83 (4.51)	89.92 (4.08)	119.80	<0.001	66.71	77.17
RP	84.58 (8.91)	84.58 (3.96)	100.00 (0.00)	100.00 (0.00)	100.00 (0.00)	309.78	<0.001	68.16	84.61
BP	76.25 (4.33)	85.92 (4.17)	95.83 (4.17)	95.42 (3.96)	96.25 (4.33)	64.48	<0.001	82.93	89.07
GH	66.25 (4.33)	75.83 (4.17)	82.08 (8.38)	82.92 (7.53)	83.33 (6.85)	21.51	<0.001	71.75	77.69
Mental health
VT	56.25 (4.33)	66.25 (4.33)	76.25 (4.33)	76.67 (4.44)	77.08 (3.96)	64.00	<0.001	63.11	69.39
SF	46.67 (4.44)	71.67 (8.35)	97.08 (4.50)	97.92 (3.96)	97.50 (3.37)	208.62	<0.001	64.47	79.14
RE	87.08 (4.50)	93.33 (2.46)	97.92 (3.96)	89.83 (4.51)	89.92 (4.08)	25.32	<0.001	90.82	94.74
MH	81.67 (4.44)	83.33 (2.46)	87.08 (3.96)	87.97 (3.34)	87.92 (3.34)	6.68	<0.001	82.58	85.48

[i] Data are presented as the mean (SD). SF-36, 36-item Short Form Health Survey; PF, physical functioning; RP, role-physical; BP, bodily pain; GH, general health; VT, vitality; SF, social functioning; RE, role-emotional; MH, mental health.

Table IV. Literature review of functional outcomes following rotationplasty.

Table IV.

Literature review of functional outcomes following rotationplasty.

First author, year	No. of patients	Mean age, years	Mean follow-up, years	Rehabilitation type	Knee (ankle) joint ROM, °	Muscle strength (0–5)	MSTS score	TESS	6mWT, meters	TUG, sec	(Refs.)
Winkelmann, 2000	8	5.9	5.3	Physiotherapy	0-80	Not available	22.5	Not available	Not available	Not available	(29)
Hahn et al, 2003	26	21.4	4.8	Not available	−11-80	Not available	Not available	Not available	Not available	Not available	(31)
Hopyan et al, 2006	5	10.4	8.6	Not available	Not available	Not available	20.1	88.9	Not available	Not available	(30)
Ginsberg et al, 2007	4	14.5	4.3	Not available	Not available	Not available	27.5	95.6	Not available	5.6	(32)
Bekkering et al, 2012	7	14.9	2.0	Not available	Not available	Not available	Not available	85.0	430.0	Not available	(28)
Gradl et al, 2015	12	19.0	14.0	Not available	Not available	Not available	19.2	Not available	Not available	Not available	(33)
Morri and Forni, 2017	1	31.0	1.0	Physiotherapy	0-95	4.5	24.0	87.0	365.0	7.7	(10)
Benedetti et al, 2016	25	9.3	15.0	Not available	Not available	Not available	24.0	Not available	Not available	Not available	(34)
Gulia et al, 2023	14	24.0	11.1	Active and passive ankle joint activity training and crutch walking	Not available	Not available	26.0	Not available	Not available	Not available	(23)
Grimsrud et al, 2020	8	11.6	18.4	Not available	Not available	Not available	19.6	90.0	Not available	Not available	(37)

[i] MSTS, Musculoskeletal Tumor Society; TESS, Toronto Extremity Salvage Score; 6mWT, 6-min walking test; TUG, timed up and go; ROM, range of motion.

Table V. Literature review of 36-item Short Form Health Survey scores following rotationplasty.

Table V.

Literature review of 36-item Short Form Health Survey scores following rotationplasty.

First author, year	No. of patients	Mean age, years	Mean follow-up, years	Rehabilitation type	Physical health				Mental health
					PF	RP	BP	GH	VT	SF	RE	MH	(Refs.)
Forni et al, 2012	20	26.9	17.2	Not available	89.3	81.3	88.2	83.6	71.8	81.2	83.3	80.8	(36)
Harris et al, 2013	1	10.0	3.0	Progressive weight-bearing, basketball and shooting	85.0	100.0	100.0	85.0	80.0	100.0	100.0	84.0	(35)
Gradl et al, 2015	12	19.0	14.0	Not available	80.4	78.1	74.1	71.8	75.0	98.9	88.2	89.6	(33)
Morri and Forni, 2017	1	31.0	1.0	Physiotherapy	60.0	50.0	100.0	76.0	80.0	75.0	100.0	84.0	(10)
Grimsrud et al, 2020	8	11.6	18.4	Not available	45.1	51.8	50.1	48.3	49.9	53.1	55.3	53.3	(37)

[i] PF, physical functioning; RP, role-physical; BP, bodily pain; GH, general health; VT, vitality; SF, social functioning; RE, role-emotional; MH, mental health.

Discussion

It has been reported that rotationplasty exhibits better gait outcomes compared with above-knee amputation or knee joint replacement for patients with malignant bone tumors of the knee, since these patients can even run and climb stairs after surgery. More particularly, young patients with bone tumors of the knee who undergo rotationplasty can have almost normal lower limb function after the procedure, thus showing higher satisfaction rates (20,21). Currently, rotationplasty is commonly considered as an alternative to above-knee amputation for pediatric and infant knee joint malignant tumors (22–24). A previous study also demonstrated that patients who received rotationplasty could participate in high-level sports (25). Due to the complexity and seriousness of bone tumors, postoperative rehabilitation faces enormous challenges. One of the main rehabilitation tasks in the field is managing patient expectations. The present study provided a detailed description of a postoperative rehabilitation strategy and evaluated the long-term functional outcomes and quality of life of patients after rotationplasty. To address the expectations and concerns of patients and their families, the present study aimed to establish a rehabilitation guidance strategy for the postoperative functional recovery of patients and depict a timeline of functional changes.

Abdelgawad et al (26) suggested that knee joint amputation could result in extensive bone and muscle structure loss, thus leading to significant sensory-motor shock, which could in turn affect neurological motor control and balance function. In the present study, the postoperative rehabilitation process consisted of three stages. Training content and difficulty were gradually increased based on the postoperative physical rehabilitation of the patient, until their limb function reached optimal levels. After the patient regained consciousness, the status of the affected foot's nervous system, skin color and pulse was examined. At the same time, early muscle lengthening and pain-free training for knee (ankle) joint mobility were performed to promote the establishment of new neural pathways and restore foot sensory nervous systems. The focus of early rehabilitation for patients is to adapt to the new knee (ankle) joint and the replacement of its function by the rotated ankle joint. Additionally, it also aims to restore the patient's proprioception and enhance the strength of the affected foot's sole muscles. Therefore, training methods should be gentle and slow, and not affect wound healing or cause damage. Gait training simulates daily life scenarios, thus enhancing the ability of the patient to perform daily activities and improving their quality of life. Stability of the pelvis and knee (ankle) joint is very important when walking (27). During initial tissue healing, particularly within 3 months postoperatively, walker-assisted standing rehabilitation training was carried out to improve the stability of the pelvis and knee (ankle) joint.

Consistent with the results of the present study, previous studies indicated that patients who underwent rotationplasty displayed good lower limb function (28–34) and a higher quality of life (35–37). However, the present study found that patients could achieve similar functional outcomes at 6 months after surgery compared with the reported results found at 1 year after surgery in a previous study (9). In the present study, at 1 year postoperatively, the functional outcome of the patients was superior compared with that observed in other studies, particularly in terms of the knee (ankle) mobility and muscle strength recovery, which reached near-normal levels. The quality-of-life scores at 1 year postoperatively were also higher compared with those reported in previous studies. Furthermore, the patients exhibited a high degree of acceptance of their physical appearance, with a mean RP score of 100, indicating a high level of satisfaction. Therefore, early rehabilitation is necessary and formulating appropriate rehabilitation programs for patients can promote the effective and rapid recovery of the lower limb function. Importantly, the results also demonstrated that lower limb function and quality of life improved rapidly in the early postoperative period, while no statistically significant differences were observed at all time points after ~1 year post-surgery.

Different tumor types, chemotherapy protocols and the patient health status exhibit significant effects on the outcomes of rehabilitation. Different types of tumors are characterized by different growth patterns, metastatic tendencies and prognoses. Therefore, the rehabilitation process should also take into account the effect of these factors and match the clinical treatment to them (38). Chemotherapy is commonly associated with the occurrence of several adverse effects, such as nausea, vomiting and fatigue. These effects can negatively affect both the physical and psychological well-being of patients. It is crucial to implement appropriate strategies to minimize the impact of these side effects on the overall well-being and quality of life of affected patients (39). Furthermore, the basic health status and immune function of the patient are vital factors that can affect rehabilitation outcomes (40). In order to guarantee the most favorable outcomes, the duration of muscle contraction was calibrated to the patient's level of discomfort and their actual condition throughout the rehabilitation process. This individualized approach enabled the creation of a personalized rehabilitation program for each patient. In the current study, the variability and complexity of tumor rehabilitation were considered as significant challenges and key areas of focus.

In summary, rotationplasty is an effective surgical method for treating malignant bone tumors of the lower limb, thus preserving lower limb function and improving the quality of life for patients. Therefore, rotationplasty deserves to be established in clinical practice. Rehabilitation strategies should be individualized based on the patient's actual condition, and the early selection of the appropriate rehabilitation strategy is of great significance. The longitudinal evaluation of postoperative functional outcomes could assist clinical physicians to analyze the results obtained, and provide more effective guidance and management for patients undergoing postoperative rehabilitation.

Functional rehabilitation following rotationplasty has a profound effect on clinical practice. Rehabilitation not only improves physical function recovery and quality of life, but also assists patients in reintegrating into social life and the workplace, and reduces social isolation and disease-induced psychological issues (41,42). However, future studies should prioritize the exploration of personalized rehabilitation protocols that consider patient-specific individual differences. Additionally, further research is needed on the development of innovative rehabilitation techniques and strategies for long-term rehabilitation and relapse prevention. These efforts could ultimately contribute to the establishment of an evidence-based guideline for rehabilitation after rotationplasty, eventually improving rehabilitation outcomes and quality of life.

Although the present study yielded valuable findings, it is important to acknowledge that several limitations could affect the interpretation of the results. The rarity of rotationplasty has resulted in a scarcity of literature on the subject. In the previous literature, few studies have described specific rehabilitation methods, making it difficult to systematically and accurately compare the methodology of this study with others. A total of 12 participants were included in the present study, each with a satisfactory outcome. However, to verify the reliability of the results, a larger sample size is needed. Therefore, future studies with a larger sample size should be carried out for a more comprehensive investigation of the 5-year survival and cure rates, thus verifying the results of the current study. Given the significant heterogeneity among patients with tumors, further research is needed to comprehensively explore and understand these confounding factors in greater detail. This could help to improve patient outcomes and quality of life.

Acknowledgements

Not applicable.

Funding

This study was supported by the National Natural Science Foundation of China (grant no. H0911-82071413).

Availability of data and materials

The data generated in the present study may be requested from the corresponding author.

Authors' contributions

ND and XZ contributed to conception and data collection. ND, JD and JY designed and conducted the study. ND, MX and YS analyzed and interpreted the data, and wrote the manuscript. ND, XZ, JD, JY, MX and YS confirm the authenticity of all the raw data. All authors read and approved the final version of the manuscript.

Ethics approval and consent to participate

This retrospective study was approved by the Institutional Review Board of the Fourth Medical Center of the Chinese People's Liberation Army General Hospital (approval no. 2023KY037-KS001; Beijing, China). All patients and their duly authorized representatives provided written informed consent to participate in the study. All methods were performed in accordance with relevant guidelines and regulations.

Patient consent for publication

All patients and their duly authorized representatives provided written informed consent for the study to be published.

Competing interests

The authors declare that they have no competing interests.

References