Rotationplasty

Overview

Rotationplasty is a limb salvage procedure that removes the knee while preserving the lower leg, providing an option for upper leg surgery that maximizes mobility and functionality. When faced with the necessity to remove the middle section of the leg, you essentially have two options: either amputate from the middle down or retain the lower portion and reattach it to the upper section, which is the purpose of rotationplasty. The procedure involves rotating the lower leg 180 degrees before it is reconnected.

This approach is an alternative to above-the-knee amputation. During the surgery, the damaged or diseased upper leg is removed, and the lower leg, including the shin, ankle, and foot, is attached to the remaining thigh. The key feature is that the lower leg is rotated so that the foot points backward, enabling functional use.

Rotationplasty is an uncommon surgical procedure, and only a few surgeons have extensive experience with it. Therefore, it’s crucial to seek out a medical center with a proven track record in performing rotationplasty. The procedure is complex and demanding for both the surgeon and the patient, so it is essential for both parties to thoroughly evaluate and consider the decision before proceeding. Nevertheless, for specific individuals and under particular circumstances, rotationplasty might be the most suitable option.

Reasons for undergoing the procedure

This procedure is most commonly used for bone cancer, such as osteosarcoma and Ewing sarcoma, which predominantly affects children and teens rather than adults. Consequently, rotationplasty is more frequently performed on younger patients.

Another reason for rotationplasty in children is congenital defects like congenital femoral deficiency (CFD), where an underdeveloped femur can be replaced by the tibia, with the knee reconfigured to function as a hip joint. CFD often coexists with fibular hemimelia, a condition that shortens the shin.

Though less common, rotationplasty may also be considered for traumatic leg injuries, persistent infections, or cancer metastasis to the leg.

Children are ideal candidates for this kind of surgery due to their growing bones, which adapt and grow with the reconstructed leg. While adults do not benefit from this growth advantage, rotationplasty can still be a viable option in certain cases.

Risks

The primary risk of rotationplasty is the appearance of the leg, which may require time to adjust to. Not everyone is comfortable with the visual changes, so it’s important to carefully consider this aspect alongside other factors, such as your tolerance for physical limitations.

Surgical risks include:

• Loss of blood flow to the leg (ischemia): This can result from a blood clot or complications with the connection between blood vessels (anastomosis).
• Compartment syndrome: Severe swelling can increase pressure within the leg, impairing blood flow to the tissues.
• Nerve injury: While minor nerve damage is common and generally heals quickly, more severe damage can be permanent.

Potential complications during recovery may involve:

• Infections: These can hinder the healing process.
• Delayed union: There may be delays in the fusion of the tibia and femur.
• Improper alignment: Issues with the alignment of the knee or hip joints can affect stability.

Procedure

After rotationplasty, your ankle, which now bends backward compared to your knee, effectively serves as your new knee joint. This procedure involves connecting the lower segment of your tibia (shin bone) to the upper segment of your femur (thigh bone) to fill the gap created by the removed section. In this setup, the lower tibia replaces the lower femur, and your rotated ankle takes on the function of the knee joint.

As a result, you have a complete and functional upper leg, allowing you to fit a prosthesis to your new knee joint. This enables you to walk and run normally. When sitting or standing, your “knees” will align and bend together, making it challenging to distinguish between your two legs when wearing pants.

Before the procedure

Rotationplasty surgery requires thorough preparation and planning, which includes:

• Education: It’s essential to have realistic expectations about the appearance of your leg post-surgery. Your healthcare provider may show you images or videos of others who have undergone the procedure and discuss what you can expect during recovery and rehabilitation. Mental and emotional readiness is crucial for navigating the recovery process.
• Physical examination: Your healthcare provider will assess the range of motion in your hip and ankle joints and evaluate the function of your sciatic nerve, which is critical for the success of the surgery. Ensuring that this nerve is functioning properly is vital for the procedure.
• Imaging examination: Before scheduling the surgery, your provider may order X-rays, an MRI (magnetic resonance imaging), or a CT scan (computed tomography scan). These imaging tests help the surgical team evaluate the condition of your leg, plan the procedure, and gauge the likelihood of a successful outcome.
• Prosthesis preparation: Your healthcare provider may create a mold of your foot prior to surgery to design a temporary prosthesis. This temporary prosthesis will be used to aid your recovery until your permanent prosthesis is ready.

During the procedure

Rotationplasty involves several key steps:

• Anesthesia: General anesthesia is administered to ensure you are asleep and pain-free throughout the procedure.
• Amputation: The surgeon removes the damaged or diseased section of your leg. Typically, this involves removing the lower part of the thigh, the knee, and the upper portion of the shin, although the specific areas removed can vary by patient. In cases of bone cancer, the surgeon will also excise the tumor along with a margin of healthy tissue to ensure complete removal.
• Reattachment: The remaining portion of your lower leg is reattached to the remaining upper leg, including bones, blood vessels if necessary, muscles, and skin. The lower leg is rotated 180 degrees, so the heel faces forward and the toes face backward.
• Stabilization: To secure the leg in place, the surgeon uses plates and screws or a rod. This hardware supports the connection between the bones during the healing process. Over time, the bones will fuse to form a single, unified structure.

After the procedure

Following the procedure, you will likely spend one to two days in the intensive care unit (ICU) before transitioning to a recovery room for several additional days.

The surgery typically lasts between four and ten hours.

Outcome

Rotationplasty main alternatives includes the following:

• Upper limb amputation using an above-the-knee prosthesis.
• Limb salvage utilizing bone grafts or prosthetic bone replacements to replace amputated portions.

The key distinction is that rotationplasty utilizes parts of your own leg, preserving nerves and blood vessels and allowing for natural growth, which is particularly beneficial for children.

Additional advantages of rotationplasty include:

• Increased durability: Using your own leg can enhance your ability to engage in activities like running and jumping, with a reduced likelihood of needing further surgeries.
• Fewer complications: It avoids issues associated with amputation and metal or bone reconstructions, such as phantom limb pain, bone graft failures, and infections.

The complete recovery of your leg bones typically takes between three to six months. If you undergo chemotherapy for bone cancer, the healing process may extend beyond this timeframe. During recovery, you may need to use crutches or a wheelchair to move around. Once your incision has healed and the swelling has subsided, you can begin using a prosthesis, which will act as the lower part of your leg and foot.

Although rotationplasty is a complex procedure, it rarely results in failure. Potential complications can arise if the leg’s blood supply is compromised or if the healing process is hindered. Chemotherapy and other cancer treatments may similarly affect healing, much like other limb-saving methods. However, most patients who undergo rotationplasty recover successfully and report long-term satisfaction with the outcome.

Physical therapy is essential for recovery after rotationplasty. A physical therapist will help you rebuild strength and flexibility in your hip and ankle joints. They will also assist you in adapting to the use of your ankle joint as a new knee, which requires retraining your brain and nerves to coordinate with your prosthesis and adjust to the new functionality of your lower leg.