Randall Reviews the Advantages of Rotationplasty in Lower-Extremity Sarcomas

R. Lor Randall, MD, FACS

Rotationplasty has better functionality and requires less maintenance compared with endoprosthetic replacement, making it the ideal approach for certain children with lower-extremity sarcomas, according to R. Lor Randall, MD, FACS.

“These biologic procedures are durable, and quite functional. They come with cosmetic concerns, but it’s fair to say in the past 10 years, with the propagation of social media, that more and more of these young people are becoming voices for this procedure,” said Randall.

Rotationplasty is a durable and biologic reconstructive approach for growing children with lower-extremity sarcomas following resection. The approach, which serves as an alternative to amputation, allograft reconstruction, and endoprosthetic reconstruction, can spare patients phantom pain, limb-length discrepancy, and endoprosthetic complications, such as loosening, infection, and wear.

Additionally, rotationplasty has been associated with favorably functionality compared with amputation and alternative limb-salvage procedures, and psychosocial well-being has not been shown to be compromised in patients with rotationplasty.

Moreover, patients who have undergone rotationplasty can freely return to high-impact activities, such as skiing, running, wrestling, and lacrosse compared with patients who have undergone endoprosthesis.

In an interview with OncLive^®, Randall, The David Linn Endowed Chair for Orthopaedic Surgery and professor and chair of the Department of Orthopaedic Surgery, University of California Davis Health, discussed the advantages of rotationplasty for oncologic and non-oncologic indications in children and young adults.

OncLive^®: How is biologic reconstruction used in children with sarcoma?

Randall: We use biologic reconstruction in young adults and children with bone sarcomas in the lower extremity. It’s not exclusive to use in sarcoma surgery, but it’s probably the dominant indication. There are other pediatric developmental conditions whereby sometimes this procedure is used as well. The title of the procedure is rotationplasty, and it is a procedure whereby you make the ankle into the knee. Sometimes you make the knee into the hip by rotating it around. It’s shocking to anyone who hears it for the first time, but if you look at your ankle and point down, you realize that’s like extending your knee 180 degrees backwards. When you bring your ankle up, it’s like flexing your knee 180 degrees backwards.

Sometimes in these children, we will remove the knee, bone, muscle, tendon, and transport up the shin, the tibia, and connect it to the remaining femur 180 degrees backwards. So now you have the foot on backwards, and you attach a prosthesis onto it, and it works like a below knee amputation, if you will.

The beauty of this procedure is that it’s 100% biologic. In many of the young people who get bone sarcomas, you have to take out this beautiful piece of real estate because it’s laden with cancer. What modern medicine is often doing now is putting in big metallic prostheses that continue to improve, and they have now noninvasive, expandable prostheses that will grow with the children and things of that sort, but it is still a relatively glorified car part. It is still a device that, over the long haul, will ultimately fail. If the children or the young people survive their cancer, and more and more of them are, then it’s just a matter of time until they inherit this orthopedic problem and have all these ongoing issues with the reconstruction of their prosthesis or of their leg.

[Patients] are becoming advocates, because they get into these [online] chat rooms, where other families go, who are looking at options, and these chat rooms are filled with people who’ve had rotationplasty or they’ve had endoprosthetics, and the kids who have had rotationplasty are saying that it’s great. [They might say]: “I’m sure my foot looks a little bit funny, but I use that as a badge of honor and I haven’t seen my orthopedic surgeon in 5 or 10 years.” Whereas the people with these limb salvage devices say every so often: “I have to go and get a bushing changed. I need to do something this, get something there. My orthopedic surgeon says I should not do this, and I should not do that. They say no, no, no.”

But the kids who have had rotationplasty, when they see their orthopedic surgeon, they hear, “Go, go, go. Just wear a helmet.” [They can] go skiing, skateboarding, whatever [they] want. [They should] just be careful, whereas with these endoprosthetics, we try to restrict their activity because we know that it’s going to wear on it.

I’ve done a bunch of [these procedures], but I did one recently for a non-oncologic indication. It’s probably the first or maybe the second time that I’ve done one for a non-cancer indication. We did it at the Shriners Hospital in Northern California and it was the first time they had done it. I gave this whole in-service ahead of time to the staff and we went through the process. The surgery went very well. It was executed exceptionally well.

I want to raise awareness about this [procedure]. Occasionally, people will hear about it. Lots of surgeons do it, but lots of surgeons don’t do it, unfortunately. This is an important [topic] to bring up because anyone reading this will at least now have heard of rotationplasty. The message to medical oncologists and/or pediatric oncologists is to find out more about rotationplasty. Ask the families that they care for [about it] when they’re getting their neoadjuvant therapy before surgery to at least have a discussion with the surgeon about whether rotationplasty is right for them. This is a very nuanced discussion. Rotationplasty is not for every child; it’s not the right answer for everyone. Medical oncologists and pediatric oncologists should be aware of this procedure and make sure that families have at least been counseled on whether this is the right procedure for them.

How long is the surgery?

It’s anywhere from 4 to 8 hours depending on a variety of things. Usually, 4 to 6 hours is [how long it takes]. If it’s a cancer operation, it takes a bit longer. Or if [the patient has] had prior surgery, it takes a bit longer because of scarring, but if it’s a non-cancer operation, and [the patient has not] had any other interventions, you can usually do in 3 or 4 hours.

Which patients are ideal candidates for rotationplasty?

The ideal candidate for this procedure is a young person, ideally, still skeletally immature. Girls up to age 12 and boys up to age 14 or so with some growth remaining who have a primary bone sarcoma of the distal femur, sometimes the proximal femur and proximal tibia, who have not had any other surgeries. [Though patients] can be a little bit older, sometimes they would have had prior procedures, etc. You should be discretionary, but [the procedure] should always be a consideration for these young people in those ideal situations.

How do recovery times compare between rotationplasty and endoprosthetic replacement?

I always joke with the families that if you can’t grow hair, you can’t grow bone. A lot of these kids are on chemotherapy [and] they have alopecia. They can’t do the osteosynthesis of healing the bone very well because of the chemotherapy. We have to protect them anywhere from 6 to 12 weeks. If they’re not getting chemotherapy, like the child I just [operated on], usually by 6 weeks, we have them weight bearing.

The other consideration is the younger they are, the more neuroplasticity they have. Meaning that they can quickly start to know that when they bring up their foot, they’re flexing their knee, and when they point their foot down, they’re straightening their knee. For someone of my age, if I’m going to have this [procedure done], I’m going to struggle with that, but for someone who has a developing brain and neural networks, it’s really quick [and amazing] how fast they adjust.

What has kept rotationplasty from becoming the predominant approach?

Historically, there’s some cultural bias because of the aesthetics. The champions, meaning the patients and the families that have been through this, realize what matters is not so much how it looks, but how it functions and the lack of need for maintenance. That part of it is gaining a lot of traction, and there are more and more rotationplastys. I suspect there are more rotationplastys happening in the past 10 years than were happening the 10 or 20 years before that, just because there are so many advocates who have a voice now through social media to be able to espouse this, that it’s become so attractive.

The other side is it is a technically difficult operation. You take out all the real estate from where you’re going to rotate up and then to where you rotate. So, from the upper limb to the lower limb, you just have the blood vessels and the relevant nerves––all the muscle, all the bone, all the soft tissue, all the skin are gone. You’ve got as few as 3 spaghetti noodles connecting. Sometimes they branch, so it’s even more and they’re even smaller. Then you have to rotate them up, carefully coil them up or re-anastomose them and then attach the limb. It’s a very technical operation and not all surgeons are comfortable with it. Hopefully, [the number of surgeons comfortable performing the operation] will increase. Hopefully, more will open their minds to it and consider learning the technique and offering it to select patients.

Given current follow-up, what do we know about the effects of rotationplasty?

Early complications can include infections. There can be ischemic insult to the limb if there’s a blood vessel issue. Overall, functional and psychosocial data are pretty sparse, but the little data that are out there are showing more and more positive outcomes. You can just [look at] YouTube and see all these extreme skiers and athletes doing this with the rotationplasty; they really do embrace it. The experience is out there.

What area of formal research could confirm the benefits of rotationplasty?

I would like to voice a call for doing patient-reported outcomes [PROs] for these kids to use PROMIS scores and others to really show convincingly that these patients really do benefit. The problem is few patients have this [procedure]. All of us, even those of us who do a lot of them, don’t do enough to power a study. It might be the musculoskeletal tumor society, it might be connected to an oncologist society, it might be some society for surgical oncology, that is able to use these PROs to really prove that these patients, when indicated appropriately, have very good physical function, minimal pain function or pain issues at all, and psychosocially are as adjusted as anybody.

Could rotationplasty become the predominant approach in patients without cancer as well?

That opens a whole discussion about what these issues are. This child was born without an upper femur bone and had multiple valiant attempts to try and lengthen the femur and grow a normal limb, but he ended up getting so much scar tissue around the knee that his knee became fixed. He basically had a short peg leg. He was at least 15 cm short in the limb from his ankle to his pelvis, and it was all working as a straight peg leg because his knee was so scarred in. His ankle worked beautifully, but his ankle was sitting on a platform not doing anything with a 15-cm shoe lift.

We were able to then turn the ankle around and make it like a knee. He still has a bad hip, and that’s an issue, but we’ll do a gait analysis at the [Shriners Hospital] and see how he does.

[Ultimately, the answer] really depends on the indications. I think this [procedure], for kids are born with abnormalities around the hip and knee where they can’t get good function, is a great operation to help some of those kids, using surgeon discretion.

Reference

1. Bernthal NM, Monument MJ, Randall RL, et al. Rotationplasty: beauty is in the eye of the beholder. Oper Tech Orthop. 2014;24(2):103-110. doi:10.1053/j.oto.2013.11.001