If your child needs surgery for a cancerous tumor in the leg bones near the knee, a novel surgical technique called rotationplasty can offer better mobility and preservation of an active lifestyle.
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Children who have osteosarcoma — a type of bone cancer that can start around the knee — usually will undergo chemotherapy and/or surgery. However, partial limb removal may be necessary when it is no longer possible to save the bone.
Rotationplasty could be an option for some of these young patients. The technique is a type of autograft, which is bone borrowed from a different part of a patient’s body and moved into a new location. Rotationplasty preserves the lower limb by re-attaching it to the thigh bone and repurposes the ankle as a knee joint.
The procedure is most often used for children younger than age 12 because of a young child’s tremendous ability to adapt to a body part that is repurposed for a different function, says orthopedic surgeon Nathan W. Mesko, MD, Center Director of Orthopedic Oncology and Trauma at Cleveland Clinic.
The procedure, however, is not frequently performed in the United States, so it’s important for parents exploring this option to find the right medical center with experienced physicians and appropriate facilities and support.
“Rotationplasty is rarely done in the United States — fewer than 10 procedures annually — because it’s performed in a very select group of patients and requires an alteration in the appearance of the leg by turning the ankle joint 180 degrees and re-purposing it to function as the knee joint,” says Dr. Mesko, who has performed the surgery.
“This procedure is best for this age group because these children have high degree of malleability and ability to conform to new functional demands,” Dr. Mesko says. “With a growing child, this solution provides a potential lifelong solution that can avoid complications seen with cadaveric bone or large metal implants.”
How does the procedure work?
To do the procedure, surgeons remove the section of the leg with the tumor, including the knee. They completely remove the tumor from the amputated limb, then reattach the healthy lower part of the leg to the remaining leg or thigh, rotating the lower part of the leg 180 degrees so the foot faces backward.
“We attach the leg back to the thigh bone in order to reconstruct the defect created by the tumor removal,” Dr. Mesko says. “So now the heel points forward.”
The ankle joint now functions like a knee joint, bending toward the back of the body. At the same time, the nerves and blood vessels in the reattached limb remain intact, and continue communication with the brain to help with balance and sensation.
Once the bone junctions have healed, the youngster is fitted for a prosthesis, which will attach over the repositioned foot and extend up the thigh.
“With rotationplasty, the bone will continue to grow with the child,” Dr. Mesko says. “The goal is for the ankle to remain at the same height as the intact knee when the youngster stops growing.”
Benefits over other surgical options
The main advantage of rotationplasty over other surgical options is that it preserves your child’s ability to remain active.
With rotationplasty, your child should be able to move more easily and control the prosthetic much better than a person with a typical above-the-knee amputation. Many sports remain possible, such as baseball and soccer, and running gait can be very close to normal. Many youngsters can bear weight directly on the reattached leg, even without the prosthesis being worn.
The results may look a little odd — without a prosthesis, the leg looks like a very short leg that faces backward. But this surgery may offer the best chance for your child to maintain mobility and stay active as he or she grows, Dr. Mesko says – more reliable than a large metal prosthesis reconstruction.
A vital key to the procedure’s success is an experienced professional who fits the specialized artificial limb that completes the leg, Dr. Mesko says.
“While the body can adapt, the youngster does need a quality, well-fitted prosthesis to make that limb as functional as possible,” he says.
“The ankle can actually take over the knee’s function,” he says. “And by marrying that to a specialized prosthesis, it gives your child a lifelong durable construct after healing has completed.”
This procedure has many benefits. But you and your child will want to carefully consider how your child will feel about the appearance of the transplanted limb.
“Parents should know that this radical procedure will give their child a much-altered — and possibly displeasing — appearance,” Dr. Mesko says.
After serious consideration, parents and their child may opt for an alternative so the child has a more normal-appearing leg, Dr. Mesko says.
“The issues we must weigh is the short-term cosmetic aesthetic concerns against the long-term issues, which include mobility,” he says. For some young patients, the opportunity to remain highly active throughout their life may far outweigh concerns about how the new limb looks.
Dr. Mesko sees rotationplasty as an ideal solution for active or athletic youngsters.
“Not only does this have better long-term potential for a patient to achieve high-functional status, but we can also minimize complication rates,” he says.
And children can adapt surprisingly well — often far better than their parents can imagine, Dr. Mesko says.
“While parents and families of course worry about their child’s psychological well-being, young children have an amazing ability to adapt mentally and physically,” he says.