Rotationplasty for children with bone tumors completely preserves leg function
UF Health Orthopaedics and Sports Medicine Institute has one of the premier programs in the world for treating cancers associated with the musculoskeletal system, including those in children. The orthopaedic oncology surgeons here are limb salvage specialists who focus on reconstruction after tumors are removed.
The most common primary bone tumor in children is osteosarcoma, which usually occurs in the second decade of life. When osteosarcoma or another malignancy affects the leg near the knee, the usual options for surgical treatment are amputation or a metal endoprosthesis. The latter allows the leg to look fairly normal, but even an expandable or “growing” prosthesis requires multiple repeat surgeries, and complications are frequent. What’s worse, patients will have functional restrictions throughout their lives.
UF is one of the few centers in the world where children and their parents have a third option: rotationplasty, which allows the patient to regain their leg function completely. During rotationplasty, the distal femur and proximal tibia are removed and the leg is rotated 180°, so that the ankle provides the function of the knee. The gastrocnemius complex (calf) becomes the thigh to power the ankle (now the knee). This gives the appearance of a short leg with the foot on backwards. However, the patient retains proprioception and can wear a shorter, more functional and customized below-knee prosthetic to provide the required length.
“We have one patient who is a Division III lacrosse player, we have people water skiing, playing soccer, running 5Ks,” says Andre R.V. Spiguel, M.D., an assistant professor at the UF Health Orthopaedics and Sports Medicine Institute. Another important benefit of rotationplasty is that no nerves are removed, so patients do not experience phantom pain or other neuropathy.
The choice among surgeries is difficult for parents, Spiguel notes, because the decision will drastically affect their child for the rest of their lives. “They think about issues related to socialization — ‘Is my child going to be accepted and have a normal life?’ I tell them cancer has already taken ‘normal’ away. Even if you choose cosmetic normalcy, the leg will never function like a normal leg. With rotationplasty, the child will never be told, ‘No, you can’t do that because of your leg.’ ”
Children 8 to 12 years old are the usual age group for rotationplasty, but UF Health surgeons have performed them on children as young as 5. “In someone very young it can be the only option, because they have so much growing left to do,” Spiguel says.
Some half-dozen rotationplasties are performed every year in the U.S., and one or two of those are done at UF Health. The procedure is normally a “one and done” proposition. Occasionally hardware has to be removed, or the child needs an additional surgery, but that is not the norm as with an endoprosthesis.
“I try not to convince parents what choice to make,” Dr. Spiguel continues. “But if it were my decision, it would be a no-brainer. I wouldn’t even think twice. Rotationplasty is the best surgery for a child who is still growing.”