Backfocus can be an issue, though of course if your world moves to this approach, then OTAs are designed to leave the backfocus for it. However, it doesn't need much, in particular because the simple coarse focus can be made small and simple and large enough that the fine focusing equipment fits inside it but can still take a 2" eyepiece nested inside. And of course if the actuators are in the camera they don't take backfocus.
In fact, for people making a near dedicated astrograph, the common approach would be to just get an extension tube with the right coarse focus setting for your camera, and then fine focus would be done with actuators or some other device.
I am surprised no actuators yet. They can do adaptive optics tricks for you. But more to the point, if you are taking a sensor that's used for DSLRs, they are *free* in that most DSLR sensors ship with actuators with 5 degrees of freedom already. In fact, it would be great if DSLR vendors were to give us new firmware that would let you control the actuators over USB. If so, an astro-modded DSLR would suddenly become a better astro camera than any of the dedicated ones due to its ability to do micro guiding and adaptive optics. Also because they have shutters. I wish we had shutters, so that if you have a guiding failure, or an airplane crosses the view or other such problems, close the shutter while it's happening and re-open it. Yes, you now have a 10 minute dark current exposure with only 8 minutes of exposure in it, but I suspect that can be dealt with. Better to only record the photons that came when were guiding within your margin. Electronic shutters might actually be better than physical ones.
Yes, diffraction spikes will look different if rotated. Less of an issue on refractors of course. They are artifacts, so there is no "right" way for them to look. But the cost and convenience of alt-az is no minor thing. With an actuated sensor including rotation, I think you could take superb photos from a giant dob, and that would be worth putting up with funny spikes.