Osteosarcoma is now commonly treated with chemotherapy & surgery, including rotationplasty. I have never seen a rotationplasty in real life…YET.
I say yet, because I fully expect we will see one at some point in our careers. So we better prepare for that day.
While there’s a lot of details about a rotationplasty, today’s episode covers 5 basic concepts that you absolutely MUST know about rotationplasty.
#1 – What is a rotationplasty?
Rotationplasty is a type of surgery used to treat people who have some kind of bone cancer in their leg. What happens in a rotationplasty is the knee joint is removed, and the remaining femur tibia and the ankle are reattached to each other to create a new knee joint.
Commonly the distal femur, the knee joint, and parts of the tibia will be removed as part of the surgery leaving the ankle in the foot.
Where the rotation component comes in is that the ankle joint is rotated 180° and then reattached to the distal femur. So now the foot is pointing backwards compared to how our foot is normally oriented.
What this does is that it basically takes a traditional above knee amputation but creates a functional below knee amputation, so there’s still a knee joint in this lower extremity.
So the person now has a thigh with a new knee joint, and the foot/ankle can now fit into a prosthesis very similar to a person who undergoes a below knee amputation, for example.
#2 – Why is a rotationplasty used vs. other surgical approaches?
In general, a rotationplasty preserves more function for patients compared to those who undergo an amputation or even other limb salvage surgeries.
Amputation was the standard of care for patients undergoing surgery for bone cancer for a long long time. However, cancer treatment has evolved over the past few decades, and chemotherapy and surgical approaches have improved. This means that while a patient’s still happens for some patients it’s not necessarily the go to especially for our younger patients.
A limb salvage surgery was the newer procedure that replaced a lot of amputations her patients. In a limb salvage surgery, the bone is preserved as much as possible while still removing the tumor and removing as much tissue as needed to create a clean margin. A limb salvage surgery is very useful for a variety of different reasons, including improved cosmetic appearance, improved functional mobility, and improve quality of life over a traditional amputation.
Even with these advances in limb salvage surgery, there’s still some problems. For example, many patients who undergo a limb salvage surgery may not be able to fully load their lower extremity in order to participate in different physical activities.
This means they’re not able to participate in sports for example but even all so repetitive loading activities. So much of what we take for granted is repetitive loading of our lower extremities: think running & jumping.
While we as adults may not be doing these activities as often, we have to consider who is the patient population that’s undergoing these types of surgeries. They tend to be our younger patients: children, adolescents, even young adults. These activities are very much a part of their everyday life, or at least they should be.
As a patients get older, their ability to work in very physically demanding jobs may be limited again because of the loading limitations for their lower extremity.
Rotationplasty addresses a lot of these concerns.
Again, because the rotationplasty creates a new intact knee joint, this can increase the loading capability of this person’s lower extremity. Meaning that these patients can be much more physically active than a person who underwent an amputation or other limb salvage surgeries.
#3 – How does rotationplasty change leg function?
With the rotation of the ankle and foot 180 degrees, you can imagine that this changes the function a little bit. But this rotation allows for the Foot and Ankle to be oriented more like a traditional knee joint would be. the new knee joint can undergo flexion and extension just like we expect a normal knee joint to do. But now instead of traditional knee flexion knee extension it’s actually the ankle that’s doing this job backwards. So when the person does ankle dorsiflexion this is actually knee flexion. And when the person does ankle plantar flexion this now becomes knee extension. It’s a little bit of a brain teaser but once you slow down to think about it it makes a lot of sense.
#4 – These patients can be extremely active after a rotationplasty.
Due to the increased loading of a new knee joint after rotationplasty compared to traditional amputations, the patients can participate in very physically demanding activities and occupations.
In fact we should encourage these patients to be as active as possible. and this is for multiple reasons.
- Patients who are diagnosed with cancer will be less active than age-matched healthy peers.
- Survivors of childhood cancer tend to be less active than their normally developing peers.
- Physical activity and exercise are beneficial for many reasons, including improved health and potential decrease in the risk of developing a future cancer.
With a rotationplasty, patients can participate in very physically demanding activities & even occupations.
#5 – These patients need PT!
Patients can have significant side effects as a result of their previous cancer treatments even before rotationplasty ever happens.
If you recall from our previous episodes, we talked about chemotherapy is very common for patients to undergo both before and after surgery for an osteosarcoma. Some of these chemotherapies can include doxorubicin, cisplatin, & methotrexate, all of which can contribute to significant short-term and long-term dysfunction.
For example, platinum-based chemotherapy are known to cause issues with chemotherapy-induced peripheral neuropathy. This can cause balance problems even prior to the patient undergoing some kind of tumor resection surgery.
These patients can also experience range of motion (ROM) and muscle strength impairments that affect their ability to be fully mobile.
PT for patients undergoing a rotationplasty can be broken up into several stages: pre-surgery, immediately post-surgical, & more long-term rehab.
Rotationplasty is becoming more common in the treatment of osteosarcoma, Ewing sarcoma, & other diagnoses. While you may not treat this patient now, you could very well encounter a patient who underwent a rotationplasty at some point in your career.
So now I want to hear from you: what did I miss? What else would you include in this episode about rotationplasty? Message me on Instagram and let me know.
Until next time this is Elise with TheOncoPT – And remember you exactly the physical therapist that your patients with cancer need. So let’s get to work.
Check out these resources:
- Compston, Amy M. PT, DPT, CRT, CLT-LANA1; Zak, Jacqueline PT, DPT2; Alexander, John H. MD3; West, Julie M. MS, PA-C4; Scharschmidt, Thomas J. MD5; Valerio, Ian L. MD6; Mayerson, Joel L. MD7 Rotationplasty Rehabilitation Protocol: A Complex Case Report, Rehabilitation Oncology: April 2020 – Volume 38 – Issue 2 – p E32-E40 doi: 10.1097/01.REO.0000000000000182
- What is rotationplasty? Shanna’s Story: