Rotationplasty: Surgical Techniques and Prosthetic Considerations

Joseph Ivan Krajbich MD, FRCS(C)

Sabrina Jakobson Huston CPO

Dr. Krajbich or an immediate family member serves as a board member, owner, officer, or committee member of Scoliosis Research Society. Neither Sabrina Jakobson Huston nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

ABSTRACT

Rotationplasty is a surgical technique that maximizes the functional potential of children and young adults who are faced with potentially high-level terminal amputation of the lower extremity or were born with a significant intercalary lower limb deficiency, such as proximal femoral focal deficiency. It is helpful to be familiar with the surgical techniques for acquired and congenital deficiencies and prosthetic management of the residual limb.

Introduction

Rotationplasty, which is also referred to in the literature as a Borggreve procedure, a Van Nes rotationplasty, or a tibial or femoral turnaround procedure, has undergone several modifications since its original description. The principle of rotationplasty, however, remains the same: a healthy, functional joint (usually the ankle) is used as a substitute for the loss of a more proximal joint (usually the knee). For the ankle to function as a biologic knee substitute, it must be brought up to the level of the contralateral knee and turned 180° to function in the plane and range of a normal knee (Figure 1). The foot distal to the ankle joint is then a below-knee component of the limb and is fitted with a transtibiallike prosthesis (Figure 2). Ideally, the child’s function then resembles that of a patient who has undergone a transtibial amputation.

Borggreve¹ first described the procedure in 1930 for a patient with tuberculosis of the knee. In the 1950s, Van Nes² published a variation of the procedure, which was used for congenital limb deficiency. Rotationplasty and its subsequent modification gained some popularity for the management of congenital femoral deficiencies,³^,⁴^,⁵ most frequently proximal femoral focal deficiency (PFFD), and it has been used in several pediatric orthopaedic surgery centers, primarily in North America and Europe. In the late 1970s in Vienna, Austria, Salzer et al⁶ modified the procedure for limb salvage in patients with osteosarcoma of the distal femur. The procedure was further adapted for use in salvage of limbs with tumor in the proximal tibia and also for lesions involving the proximal femur, where the rotated knee can be used as a substitute for a hip joint. Since then, rotationplasty has been applied in a variety of conditions where the distal part of the limb with the functional distal joint can be salvaged, but a proximal joint cannot be salvaged. The greatest barrier to the wider acceptance of this technique appears to be unfamiliarity with the procedure.⁷^,⁸^,⁹

In addition to a cooperative patient and their family, an optimal functional outcome in these procedures requires a successful surgical outcome, a diligent rehabilitation regimen, and expert prosthetic fitting. The rotationplasty prosthesis, albeit relatively inexpensive in terms of the prosthetic components, requires significant expertise on the part of the prosthetist to achieve a functionally optimal outcome.

Surgical Considerations

Indications

The primary reason for rotationplasty, compared with a terminal transfemoral amputation, is to provide a patient with a biologic knee substitute that would improve gait efficiency, energy consumption of ambulation, and the ability to walk on uneven surfaces. Ideally, the resulting function is very similar to that of a transtibial amputation.

The indications for rotationplasty or its various modifications can be classified into two main categories: (1) congenital lower limb deficiency (usually but not always PFFD) and (2) acquired deficiency with rotationplasty as a form of limb salvage. The underlying condition is most frequently a
malignant tumor in a child or a young adult, but it is also used in other etiologies, such as trauma, infection, and the failure of previous limb salvage or other reconstruction procedures.

FIGURE 1 AP (A) and lateral (B) clinical photographs of a male patient treated with rotationplasty.

The surgical technique differs for each category, so each has a separate description in this chapter. However, some general principles apply to both categories.

FIGURE 2 Clinical photographs of front (A) and side (B) views of a child with a rotationplasty prosthesis.

Prerequisites

The joint to be transferred or rotated must have functional range of motion, and its nerve supply must be intact. Vascular supply to the distal part of the limb must be preservable or reconstructible. Motor supply to the newly reconstructed joint must be present and functional.

Absolute Contraindications

The absolute contraindications are a failure to satisfy the prerequisites. A poorly perfused or insensate foot with restricted range of motion is a poor substitute for other reconstructive methods or transfemoral amputation and restoration with modern transfemoral amputation prosthesis. The procedure is contraindicated in patients with malignant tumors where adequate oncologic resection margins do not allow for major nerve preservation.

Relative Contraindications

The relative contraindications are primarily subjective. In the opinion of one this chapter’s authors (J.I.K.), the primary reason that this procedure is not more widely performed, particularly in patients with PFFD and young (first and second decade) patients with cancer, is the treating surgeon’s unfamiliarity with the procedure. The somewhat odd appearance of the reconstructed limb can occasionally be a deterrent. Functional expectations, particularly in patients with a tumor, also play an important role.¹⁰ An active lifestyle versus a relatively sedentary lifestyle but better cosmesis with potential multiple reoperations in the future may weigh on the child and any parental decision regarding the procedure chosen. The patient and the family must be comfortable with the decision to proceed with the proposed surgical approach. A lack of appropriate prosthetic services can also be a relative contraindication; however, this criterion should be limited only to very underserved areas or countries. The prosthetic componentry is relatively simple, and the skill for making the prosthesis is acquirable and learnable. Having a well-functioning rotationplasty limb and prosthesis allows excellent function resembling that of a transtibial amputation. Having a
functioning biologic knee-like joint provides for improved energy consumption in gait and improved agility and ability to walk on uneven surfaces.¹¹^,¹²^,¹³^,¹⁴^,¹⁵

Rotationplasty for Children With PFFD

PFFD is a congenital abnormality of the femur that varies in severity from a deficit primarily in the subtrochanteric region of the femur to virtual complete absence of the femur¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰ (Figure 3). For the purpose of this discussion, only true PFFD versus congenital short femur as described by Gillespie and Torode²¹ will be considered. The most frequently used PFFD classification was developed by Aitken,²² and all four types (A through D) are potentially suitable for rotationplasty if the child has a relatively normal foot and ankle complex. The presence or absence (or various degrees of dysplasia) of the hip is not a contraindication to the procedure. In patients with a reconstructible hip (Aitken types A and B) and who are deemed not be candidates for femoral reconstruction and limb equalization procedures, hip reconstruction is usually performed as a second procedure 1 or 2 years after rotationplasty. In addition, in normalizing the hip joint, the procedure allows for fine-tuning of the rotationplasty as to the length and rotation of the new thigh.²³

FIGURE 3 Clinical photograph of the lower extremities of a young child with proximal femoral focal deficiency before rotationplasty.

The rotationplasty procedure has been modified several times since first being introduced by Van Nes.² Initially, the rotation was performed through the diaphysis of the tibia and the fibula, either alone or combined with knee fusion.⁴^,⁵^,²⁴ The addition of knee fusion has been a major contribution to the surgical treatment of PFFD, with or without rotationplasty. It was first described by King and Marks²⁵ and has become a standard part of PFFD treatment.²⁵^,²⁶^,²⁷ A single-bone thigh is aligned under the hip joint, thus allowing for restoration of the biomechanical axis of the limb in the sagittal plane.²⁵^,²⁶^,²⁷ Taking advantage of knee fusion, Gillespie²⁸ and Torode and Gillespie²⁹ incorporated a substantial portion of the rotation through the knee fusion and the remainder through the tibial diaphysis.³⁰ Still, the relatively common phenomena of derotation led one of this chapter’s authors (J.I.K.) to modify the procedure even further. In most patients, the entire rotation is carried through the knee fusion, which necessitates detachment of all muscle and tendon structures crossing the knee joint and careful mobilization of the neurovascular bundles to ensure a viable functional limb.²³ Muscles and tendons are then reattached so they line up in the plane of the adjacent joint motion, thus less likely contributing to derotation.

Surgical Technique

The child is placed on a radiolucent table in a supine position, with the affected limb draped free. The posterior tibial and anterior tibial arterial pulses are marked on the skin for easy location and later monitoring. A lazy S incision is made over the knee area starting proximally and laterally, crossing the knee anteriorly at the level of the joint and curving medially and distally. The practice of one of this chapter’s authors (J.I.K.) is to first identify and dissect free the peroneal nerve on the lateral side. The biceps femoris and pes anserinus muscles and tendons are divided at the level of the knee joint. The two heads of the gastrocnemius muscles are detached as close to their origin on the femoral condyles as possible. Care must be taken not to disrupt the nerve supply to the gastrocnemius muscle because this muscle, together with the soleus, will become the reconstructed knee’s primary extensor. This process allows for good visualization of the popliteal fossa neurovascular bundle. The patellar tendon is then divided, and complete capsulotomy of the knee joint is performed, carefully protecting the posterior neurovascular structures. The collateral and cruciate ligaments, if present, also are divided. The remaining muscular structures (semimembranosus and popliteal) are then identified and divided, which allows for good exposure of the popliteal artery and vein, which are further mobilized by dividing the geniculate branches. The distal femoral epiphysis and metaphysis and the proximal tibial epiphysis and portions of the metaphysis are thus exposed. The distal femoral epiphysis together with its physis and a portion of metaphysis are excised. The extent of proximal tibial excision depends on length of the remaining femur. If the femur is very short, only a portion of the epiphysis preserving the epiphyseal plate is excised. If the femur is of a reasonable length, the whole epiphysis is removed together with the physis and a small portion of the metaphysis (approximately 5 mm). The extent of the metaphyseal excision of the femur is to some degree guided by the ease of rotation of the distal part of the extremity. Complete 180° rotation must be achievable without vascular compromise. The previously marked peripheral pulses are carefully monitored with a sterile Doppler probe. Any compromise in circulation must be addressed by additional dissection and mobilization of the vessels and/or additional shortening of the femoral metaphysis.

The procedure is then completed by arthrodesis of the tibia, which is rotated 180° to the femur using intramedullary fixation of a Rush rod and securing the rotation alignment with either a cross pin or a small plate (Figure 4). Maintaining good vascular perfusion as monitored by Doppler is critical at this stage. Any compromise must be
addressed immediately by further vessel decompression and mobilization. In very rare instances, the rotation can be controlled by cast immobilization without an internal cross pin, allowing less-than-perfect rotation but obviating the need for implants. The final desired rotation can be achieved in 1 or 2 weeks during a cast change under anesthesia.

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