Surgical Procedures: Rotationplasty

What is rotationplasty?

Rotationplasty is a surgery used in the treatment of some bone cancers (osteosarcoma or Ewing sarcoma) found in the knee or knee joint area. The bottom of the femur (the long bone in the thigh), the knee, and the upper tibia (bone below the knee) are surgically removed. The lower leg is then rotated or turned 180 degrees (to face backward), which is why it's called rotationplasty. The lower leg is then attached to the femur. For a patient to be able to have this surgery, sciatic and other vital lower leg nerves must be intact and working.

Rotationplasty is most often used in children under 12 years of age, because the bones will keep growing. Young children are also better able to learn and adapt to how their leg now works.

Some older children or adults may also be able to have rotationplasty. It may be used for those who would need an above the knee amputation due to the size of the tumor. One benefit of rotationplasty is that often the nerves can be saved, as they are needed for ankle/foot function.

How is it done?

During a rotationplasty, the part of the leg and thigh bones that have the tumor is removed, along with some healthy bone to have “clean margins.” Clean margins means that the edges of the tissue removed are free of cancer cells when looked at under a microscope. This often includes some of the lower part of the femur bone (thigh), the knee joint, and some of the top of the lower leg (tibia). The lower part of the leg, including the foot and ankle, are then rotated 180 degrees to face backward, creating a new “knee joint.” This is then attached to the thigh bone (femur).

The attached ankle joint will act as a new knee. The backward-facing foot will fit into a custom-fit artificial lower limb.

What are the benefits of rotationplasty?

Because children keep growing until adulthood, one benefit to this procedure is that the bone will continue to grow with them. This helps them be physically active. The prosthetic leg used with rotationplasty will be fitted and changed as they grow.

Options other than rotationplasty are an amputation and prosthetic knee. This limits the patient’s activity and the sports the person can do. When a child needs a prosthetic knee, many surgeries are often needed over their growing years.

Many children who have rotationplasty continue to be active, taking part in physical activities like soccer, basketball, running, skiing, bicycling, and more.

Rotationplasty keeps nerve and blood vessel function, so phantom limb pain (pain after amputation where the limb was removed) is not a side effect of this type of surgery.

What are the risks of having rotationplasty?

This is a highly specialized procedure that is not done very often. It is important to have the surgery done at a specialty center with experience in doing the procedure.

Risks and side effects of having a rotationplasty depend on the procedure, as some patients may need more reconstruction of blood vessels. General risks may be:

• Reactions to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, to not remember it, and to manage pain. Reactions can include wheezing, rash, swelling, and low blood pressure) and other medications.
• Bleeding, blood clots.
• Infection, wound healing problems.
• Injury to nerves or problems with the blood supply to the grafted lower leg.
• Poor bone fusion (connection), leading to more surgery.

What is recovery like?

Patients who have rotationplasty will often need to stay in the hospital for up to a week. Most patients will go home in a cast. The length of time in the cast depends on how the bone heals. If the patient is receiving chemotherapy, healing may take longer. Once the bone and wounds have healed, the child can be fitted for the lower leg prosthesis. During this time, the patient may need crutches or a wheelchair to get around.

Physical therapy (PT) is a key part of recovery. Therapy helps the patient learn to use the ankle joint as a knee joint, how to walk with the new leg/prosthesis, and how to wear and adjust the prosthesis. This takes some time and effort from the patient. The length of therapy can vary from patient to patient. As the child grows, they will need a new prosthesis and may need short stints of physical therapy with each new prosthesis.

Physical therapy meets with the patient and family before the surgery to test the patient’s needs and what they hope to gain after the procedure. They will talk in more detail about what to expect after surgery and in the future.

Rotationplasty may be an option for some patients with bone tumors in the leg. It can be a hard surgery to understand, especially when faced with all that comes with a new cancer diagnosis. Use the resources below to learn more about rotationplasty, see how other patients are doing after the procedure, and connect with providers who do this procedure.