ROTATIONPLASTY: BENEFITS OF AN ANKLE KNEE JOINT
Medically Reviewed by Dr. Sony Sherpa (MBBS) - August 6, 2024
Recovery, Rehabilitation, and Prognosis
Who Should Not Have Rotationplasty
When faced with the possibility of limb amputation due to a bone tumor or other medical condition, many people are unaware of the alternative option of rotationplasty.
This unique surgical amputation procedure involves removing a portion of the leg, fusing the lower leg to the thigh or hip, and using the ankle joint to create a functional knee joint with a specialized prosthetic. The procedure is preferable to prosthetics because it can preserve the nerves, blood supply, and natural leg motion.
While it may sound like something from a science fiction movie, rotationplasty has been successfully performed for decades and has helped many individuals lead active and fulfilling lives.
This blog explores rotationplasty, including when and why it is done, the procedure itself, and what to expect during recovery and rehabilitation.
Rotationplasty Procedure
The rotationplasty procedure typically takes 6-8 hours and is performed under general anesthesia. The procedure steps are:
- A surgeon makes incisions below and above the knee, removing the affected area.
- The procedure spares the central nerves and blood supply to maintain blood flow and sensation in the limb.
- The remaining portion of the leg is rotated horizontally 180 degrees and attached to the thigh.
- The surgeon knits the leg back together and places it in a cast for proper healing.
- Two additional surgeries allow the surgeon to remove the cast and assess the joint after two to six-week intervals. The surgeon applies a new cast after the first follow-up surgery and removes pins after the second follow-up.
- After healing, the patient can flex their ankle joint like their knee.
- After some time and practice, the patient walks with a prosthetic made to hold the foot in place.
The child often must grow older and wait for their other leg to reach the same size as their shortened limb.
There are more than ten variations to this procedure[1], including the Van Nes rotationplasty and the brown rotationplasty. Variations depend on what portion of the leg is removed and how the leg is re-attached. Yet all of them result in the same outcome: the ankle joint becomes a functional knee joint.
The Paley-Modified Brown rotationplasty is one of the most popular variations[2]. In this technique, most of the upper leg is removed, and the knee is inserted into the hip instead of straightening and being attached to the upper thigh. This method improves hip and leg movement as no portion above the knee is joined to the hip at an odd angle.
Why is Rotationplasty Done?
Rotationplasty is an alternative to traditional amputation. Experts recommend rotationplasty for bone tumors near the knee joint, such as osteosarcoma or Ewing sarcoma[3], for congenital short femur deformities or other similar medical conditions.
This procedure works best for children under 12 years old whose bones are still growing and can adapt to the changes more quickly. However, it has also been performed successfully on adults in some instances.[4]
While amputation may be necessary in some cases, rotationplasty offers several benefits, making it a preferred option for many individuals.
These benefits include:
- Maintaining a functional limb: With rotationplasty, the ankle joint is rotated and attached to the thigh, creating a functional knee joint. The surgeon spares the nerves and blood supply, which preserves the limbs' integrity. This preservation allows individuals to use their limbs daily and participate in sports and other physical activities.
- Better prosthetic fit: Traditional amputation often results in a shorter limb, making it difficult to find a properly fitting prosthetic. With rotationplasty, the limb is lengthened and shaped like a knee, making it easier to find a comfortable prosthetic, allowing for better mobility.
- Improved range of motion: By using the ankle as a knee joint, rotationplasty allows for a better range of motion than traditional amputation. The range of motion is especially beneficial for individuals who want to continue playing sports or participate in other physical activities.
- Reduced risk of complications: Traditional amputation can result in complications such as phantom limb pain and neuromas. Rotationplasty has a lower risk of these complications, making it a safer option for many individuals.
Beyond the physical advantages, rotationplasty has psychological benefits. Retaining a full-limb appearance can positively impact body image, self-esteem, and quality of life.
Recovery, Rehabilitation, and Prognosis
After the rotationplasty procedure, the patient will likely spend up to a week in the hospital for monitoring and pain management. Once discharged, the recipient must wear a cast for several weeks for proper healing. The cast is replaced twice after the initial operation.
Physical therapy will also be necessary for the recovery and rehabilitation process. The patient will learn how to utilize their new knee joint and prosthetic, as well as acquire strength and mobility in their new leg, with the assistance of a physical therapist. A therapist also provides exercises to help desensitize the child's limb using the prosthetic.
The patient can take 2-4 weeks to learn how to walk with a spica prosthetic[5], designed to slip over the foot and heel and strap into place.
The prognosis for rotationplasty is generally positive[6], with many individuals able to return to their normal activities and even participate in adaptive sports. The success rate is high, yet data still needs to be included. A small review of 25 patients suggests an 88% success rate, with three experiencing complications that warranted traditional amputation[7].
It is crucial to remember that a number of things affect how well the surgery goes, including the location and severity of the bone tumor or other medical condition, the age of the individual, and their commitment to physical therapy and rehabilitation.
Living with Rotationplasty
Living with rotationplasty may take some adjustment, but many individuals can lead active and fulfilling lives after the procedure. Using a prosthetic limb, individuals can participate in sports, work, and other daily activities without limitations.
It is essential to continue to monitor the limb for any changes or complications and to follow up with your doctor regularly.
Risks and Complications
As with any invasive procedure, rotationplasty has its own risks and potential complications. These may include[8]:
- Infections
- Blood clots or bleeding
- Arterial occlusion
- Severe swelling
- Nerve damage
- Delayed healing
- Ankle stiffness
- Knee instability
- Hip joint misalignment
- Prosthetic fitting issues and sores
- Leg bone fractures
In some cases, complications can result in a traditional amputation.
Discussing these risks with your doctor and weighing them against the potential benefits of rotationplasty is essential.
Who Should Not Have Rotationplasty?
While rotationplasty is a feasible option for many children and adolescents, there are some cases where it may not be recommended. These may include:
- Individuals with a femoral deficiency, meaning their thigh bone is too short
- Individuals who have had previous surgeries on their leg or hip joint
- Individuals who are not committed to physical therapy and rehabilitation
- Individuals who have a medical condition that may interfere with the healing process
It is essential to discuss your case with your doctor to determine if rotationplasty is the right option for you.
Latest Advancements and Technology
In recent years, there have been several notable advancements in rotationplasty techniques and prosthetic technologies, paving the way for improved outcomes and enhanced mobility for individuals who undergo these procedures.
Advancements in surgical techniques like rotationplasty have led to quicker recovery and improved outcomes, allowing for shorter hospital stays and faster return to daily activities.
Prosthetic technology refinements offer rotationplasty patients a more natural gait, improved motion range, higher impact resistance, better comfort, and enhanced activity stability. 3D printing for custom rotationplasty prosthetics allows for a more precise fit and better mobility for those who have had the procedure.[9]
Future innovations in rotationplasty and prosthetics, like robotic-assisted surgery, could enhance precision, improve outcomes, and optimize functional results, improving quality of life and mobility. Personalized prosthetics leveraging sensors, robotics, AI, and machine learning offer tailored adaptations for individual needs, enhancing control and function. In the future, wearable robot prosthetic exoskeletons may make walking easier for those with a rotationplasty limb[10]. Eventually, robotic prosthetics may replace the need for rotationplasty.
Conclusion
Rotationplasty is a unique and innovative surgical procedure that offers an alternative to traditional amputation. By rotating the ankle joint and attaching it to the thigh, individuals can maintain a functional limb and continue participating in sports and other physical activities. While it may not be the right option for everyone, it has helped many individuals lead active and fulfilling lives. If you or a loved one is facing the possibility of limb amputation, be sure to discuss rotationplasty with your doctor to determine if it is the right option for you.
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