Rotationplasty

What is rotationplasty?

Rotationplasty is a limb salvage procedure that preserves the lower part of your leg after removing the knee. It’s an alternative to amputation above the knee. A surgeon removes the diseased or injured upper part of your leg, then reattaches the lower part (shin, ankle and foot) to your remaining thigh. But they rotate the lower part 180 degrees before reattaching it, so your foot points backward.

Why backward?

Your ankle joint bends backward, which is the opposite way from your knee joint. But after rotationplasty, your ankle becomes your new knee. Your surgeon attaches the lower part of your tibia (shin bone) to the upper part of your femur (thigh bone) to bridge the gap left by the removed part. In this way, the lower tibia replaces the lower femur, and your rotated ankle replaces your knee joint.

This leaves you with a complete and functional upper leg. Then, you can attach a prosthesis (artificial limb) to your new knee joint. The prosthesis on the end, together with the functional knee, allows you to walk and run normally. When you sit down and stand up, your “knees” will be parallel and bend together. And when you wear pants, you might not be able to tell the difference between the two legs.

Who is rotationplasty for?

Rotationplasty is one option when you need surgery to remove part of your upper leg but want to preserve as much mobility and durability as possible. Bone cancer is the most common reason for this. Cancerous tumors that affect your leg bones, like osteosarcoma and Ewing sarcoma, are more common in children and teens than in adults. This is one reason why children have rotationplasty more often.

Congenital (present at birth) defects are another, less common reason why children have rotationplasty. For example, congenital femoral deficiency (CFD) is an underdeveloped femur. When your entire femur is unusable, your entire tibia can substitute for it, with your knee joint replacing your hip joint. (CFD often appears with another condition called fibular hemimelia, which makes your shin shorter.)

Other reasons for rotationplasty can affect children or adults, but these are rarer. They include:

• Traumatic leg injuries.
• Persistent leg infections.
• Cancer that spreads to your leg from somewhere else.

Children make the best candidates for rotationplasty because their bones are still growing. As they grow, their reconstructed leg grows with them, so they can better adapt it to their activities. Adults don’t have this advantage, but there are still cases where rotationplasty might be their best option.

How common is rotationplasty?

Rotationplasty is a very uncommon procedure. Very few surgeons have ever performed it, so it’s important to find a medical center experienced with the procedure. It’s complex and challenging for both the surgeon and the person recovering, so both parties should consider the choice very carefully before committing. However, for certain people in certain circumstances, it might be the best choice.

How do I prepare for rotationplasty?

Rotationplasty surgery requires careful preparation and planning, including:

• Education. It’s important to have realistic expectations about what your leg will look like after rotationplasty. Your healthcare provider may show you pictures or videos of other people who’ve had the procedure. They’ll also explain what you can expect during your recovery and rehabilitation. You’ll need to prepare yourself mentally and emotionally for the road ahead.
• Physical exam: Your healthcare provider will check to make sure your hip and ankle joints have a full range of motion. They’ll also check that the main nerve in the leg, your sciatic nerve, still functions well. You’ll need this nerve to be fully functional for the surgery to work.
• Imaging exams: Your provider might order X-rays, an MRI (magnetic resonance imaging) or a CT scan (computed tomography scan) before scheduling your rotationplasty. These tests help your surgical team assess the overall condition of your leg, what they’ll need to accomplish during surgery and how likely it is to succeed.
• Prosthesis preparation: Your healthcare provider may make a mold of your foot before surgery. This helps them make a temporary leg prosthesis that you can wear soon after the procedure. The temporary prosthesis helps you recover until your long-term prosthesis is ready for you.

What happens during rotationplasty surgery?

Rotationplasty includes the following steps:

• Anesthesia: You receive general anesthesia for the procedure. This medication puts you to sleep so you won’t feel pain during your surgery.
• Amputation: Your surgeon removes the damaged or diseased part of your leg. Most people will have the lower part of their thigh, knee and the upper part of their shin removed, but this may look different from patient to patient. If you have rotationplasty for bone cancer, your surgeon will make sure to remove all of the tumor, along with a margin of healthy tissue around it.
• Reattachment: Your surgeon reattaches the remaining part of your lower leg to the remaining part of your upper leg, including the bones, blood vessels if needed, muscles and skin. They rotate the lower part 180 degrees so that your heel faces toward your front and your toes face backward.
• Stabilization: Your surgeon uses plates and screws or a rod to hold the two parts of your leg in place. This hardware helps connect your bones together as your leg heals. The two bones will eventually grow together to form a single bone.

How long does rotationplasty take?

The surgery itself may take between four and 10 hours to complete. You’ll spend one to two days in the intensive care unit in the hospital (ICU). After that, you’ll spend several more days in a recovery room.

What are the benefits of rotationplasty over the alternatives?

The main alternatives to rotationplasty are:

• Amputation above the knee and using an above-the-knee prosthesis.
• Limb salvage using prosthetic bone parts or a bone graft to replace the removed parts.

The main difference between these and rotationplasty is that they rely on prosthetics or donor bone to replace your knee and leg parts, while rotationplasty uses parts from your own leg. Your nerves and blood vessels stay intact, and the leg continues to grow as you grow, which is especially helpful for children.

Other benefits include:

• More durability. Using your own leg makes it easier to return to activities like running, jumping, and high-impact sports. There’s also less risk of needing additional surgeries after rotationplasty.
• Avoiding the potential complications of amputation and metal or bone reconstructions, like phantom limb pain, bone graft failures and infections.

What are the disadvantages of rotationplasty?

The main disadvantage of rotationplasty is what your leg would look like, which can take some getting used to. Not everyone feels they could learn to accept the way their leg would look. It’s important to honestly consider this and weigh it against other factors, like how physically limited you’re willing to be.

What are the possible risks or complications of rotationplasty surgery?

Risks of surgery include:

• Loss of blood flow to the leg (ischemia). This could be due to a blood clot or a failed connection between blood vessels (anastomosis).
• Compartment syndrome. Severe swelling causes a buildup of pressure in your leg that cuts off blood flow to the tissues.
• Nerve injury. Minor nerve damage is common and usually heals in a short time. But more severe damage could be lasting.

Complications during recovery could include:

• Infections, causing problems with healing.
• Delayed union (fusing) of your tibia and femur.
• Imperfect alignment of your knee or hip joints, causing stability issues.

What is the recovery like from rotationplasty?

It may take three to six months for the bones in your leg to fully heal. If you receive chemotherapy for bone cancer after surgery, healing will take longer. You may need a wheelchair or crutches to move around during this time. Once your incision has healed and the swelling has gone down, you’ll be able to start wearing a prosthesis. You’ll learn to use this prosthesis as the lower part of your leg and foot.

Physical therapy is an important part of recovering from rotationplasty. A physical therapist will help you regain strength and flexibility in your hip and ankle joints. They’ll also teach you how to begin using your ankle joint as your new knee joint. This takes practice: You’ll have to retrain your brain and nerves to recognize your new knee and to work together with your prosthesis as your new lower leg.

While adults may take longer than children to adjust to the new leg, most people are able to walk without aid after three to six months. Within six to 12 months, you should be able to return to any activity you wish, including high-impact sports. Many people are pleasantly surprised by how functional their leg is after rotationplasty. The working knee joint gives you mobility you wouldn’t have otherwise.

How successful is rotationplasty surgery?

While rotationplasty is a complex procedure, the surgery doesn’t often fail. Failure might occur if your leg loses blood flow or doesn’t heal well. Cancer treatments like chemotherapy can sometimes interfere with the healing process. This risk is similar with rotationplasty and other limb salvage procedures. Most people recover well from rotationplasty, and they report long-term satisfaction with their results.

A note from Cleveland Clinic

Making a choice like rotationplasty is difficult and might feel very lonely. You’re unlikely to know anyone else who’s faced that choice. But thanks to social media, people living with rotationplasty are much easier to find than they used to be. They’re telling their stories, performing in sports and living their best lives on camera. Spending some time with them could help you get used to the idea of rotationplasty.