Rotationplasty: Understanding the Leg-Turning Surgery, Indications, and Recovery

What is the surgery to turn your leg around?

The surgery often referred to as "turning your leg around" is medically known as Rotationplasty. It is a highly specialized orthopedic procedure primarily performed to remove a diseased or damaged section of a limb, typically due to bone cancer, while preserving a functional limb for prosthetic use.

Understanding Rotationplasty: A Specialized Surgical Procedure

Rotationplasty is a unique and complex surgical technique that involves removing a segment of a limb, most commonly around the knee joint, and then reattaching the remaining lower limb (the tibia and fibula) in a rotated position. In this procedure, the ankle joint is rotated 180 degrees and then surgically fused to the remaining upper thigh bone (femur). The patient's own ankle joint, now positioned at the approximate level of the original knee, subsequently functions as a new knee joint within a prosthetic leg. This innovative approach aims to provide a more functional outcome compared to a traditional above-knee amputation, allowing for better prosthetic control and often a more active lifestyle.

Why is Rotationplasty Performed?

The primary indications for Rotationplasty are severe conditions that necessitate the removal of a significant portion of a bone, particularly around the knee.

• Malignant Bone Tumors: The most common reason is to remove aggressive bone cancers, such as osteosarcoma or Ewing's sarcoma, located around the knee in children and adolescents. It allows for complete tumor excision while preserving the limb's length and some natural joint function.
• Severe Trauma: In cases of irreparable damage to the knee joint due to severe injury where traditional reconstruction is not feasible.
• Congenital Limb Deficiencies: Rarely, it may be considered for severe congenital malformations where other reconstructive options are limited.

Rotationplasty is often chosen over traditional above-knee amputation because it preserves the patient's own ankle joint, which, when rotated, can serve as a highly functional "new knee" within a custom-fitted prosthesis. This allows for better proprioception, weight-bearing, and overall mobility.

The Surgical Procedure Explained

Rotationplasty is a meticulous and lengthy surgical procedure performed by highly specialized orthopedic surgeons. The general steps involve:

• Tumor Resection/Damaged Bone Removal: The surgeon carefully removes the section of the femur, knee joint, and upper tibia that contains the tumor or is severely damaged. The exact amount of bone removed depends on the extent of the disease or injury.
• Neurovascular Preservation: Critical nerves and blood vessels supplying the lower leg and foot are carefully dissected and preserved to ensure viability of the reattached limb segment.
• Rotation and Reattachment: The lower leg (tibia and fibula) and foot are then rotated 180 degrees (so the foot points backward). The remaining part of the tibia is then surgically reattached to the remaining part of the femur. This reattachment is typically secured using internal fixation devices such as plates, screws, or rods.
• Ankle as New Knee: The ankle joint, now facing backward, is positioned to function as the new knee joint. The calf muscles become the new quadriceps, and the foot and ankle muscles contribute to the new knee's movement.
• Wound Closure: The surgical site is closed, and the limb is immobilized to allow for initial healing.

Post-Operative Recovery and Rehabilitation

Recovery from Rotationplasty is a long and intensive process requiring significant commitment from the patient and a multidisciplinary rehabilitation team.

• Initial Healing: The first phase involves allowing the bone fusion to occur, which can take several months. The limb is typically immobilized in a cast or brace.
• Physical Therapy: Once initial healing permits, an aggressive physical therapy program begins. This focuses on:
  • Strengthening the muscles around the "new knee."
  • Improving Range of Motion in the ankle joint (now the knee).
  • Gait Training to adapt to the new biomechanics.
• Prosthetic Fitting: A custom-designed prosthesis is crucial. It encases the rotated lower leg and foot, allowing the ankle joint to function within the prosthetic knee mechanism. The design is tailored to maximize comfort and function.
• Neuromuscular Adaptation: Patients learn to interpret the sensations from their rotated foot as movements of their new knee, a remarkable example of neuroplasticity.

Functional Outcomes and Quality of Life

The functional outcomes of Rotationplasty are often superior to those of traditional above-knee amputation, especially for young, active individuals.

• Improved Mobility: Patients can typically walk, run, jump, and participate in a wide range of sports and activities, often with a more natural gait than with a traditional above-knee prosthesis.
• Better Proprioception: The preserved ankle joint and its sensory nerves provide a degree of proprioception (awareness of limb position) that is absent in a traditional amputation, leading to better control of the prosthesis.
• Weight-Bearing Capacity: The natural bone-to-bone connection allows for direct weight-bearing through the limb, which can be more comfortable and stable.
• Reduced Phantom Limb Pain: While still possible, the incidence and intensity of phantom limb pain can be lower compared to traditional amputations due to the preserved distal limb.

Considerations and Potential Challenges

While offering significant benefits, Rotationplasty also presents unique challenges:

• Aesthetic Appearance: The rotated foot can be aesthetically challenging for some patients and families, requiring psychological adjustment.
• Psychological Adaptation: Adapting to the new body image and function requires strong mental resilience and support.
• Surgical Complications: As with any major surgery, risks include infection, non-union of the bone, nerve damage, or blood clot formation.
• Long-Term Joint Health: While the ankle joint is remarkably adaptable, its long-term health under the stresses of functioning as a knee is a consideration, and some patients may develop arthritis over many years.

Who is a Candidate for Rotationplasty?

The decision to perform Rotationplasty is complex and made on a case-by-case basis by a specialized surgical team. Ideal candidates typically meet several criteria:

• Age: It is most commonly performed in children and adolescents because their bones are still growing, and they have excellent adaptive capacity.
• Tumor Characteristics: The tumor must be located in a specific area (usually around the knee) and be amenable to complete surgical removal while preserving the neurovascular bundle to the lower leg.
• Overall Health: The patient must be healthy enough to undergo a major surgery and extensive rehabilitation.
• Patient and Family Commitment: A strong commitment to the challenging rehabilitation process is essential for a successful outcome.

Conclusion: A Specialized Approach to Limb Salvage

Rotationplasty is a testament to the ingenuity of modern orthopedic surgery, offering a unique and highly functional alternative to traditional amputation for specific conditions, primarily bone cancers around the knee. By transforming the ankle into a functional knee joint, it provides patients, particularly young individuals, with the opportunity for significantly improved mobility, proprioception, and quality of life, allowing them to lead active and fulfilling lives. It stands as a powerful example of how advanced surgical techniques can redefine possibilities for limb salvage and functional recovery.