Rotationplasty—a unique surgical procedure with a functional outcome

AORN Journal,  August, 2006  by Jane M. Wick,  Kelly M. Alexander

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The article "Rotationplasty--A unique surgical procedure with a functional outcome" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Aug 31, 2009.

Complete the examination answer sheet and learner evaluation found on pages 217-218 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES

After reading and studying the article on rotationplasty, nurses will be able to

1. identify the indications for appropriate selection of patients for the rotationplasty procedure,

2. discuss nursing care specific to patients undergoing rotationplasty,

3. describe the rotationplasty procedure,

4. discuss complications of the rotationplasty procedure, and

5. explain the advantages of the rotationplasty procedure.

In a perfect world, birth defects and childhood cancer would not exist. In reality, however, these conditions do occur, and inventive solutions must be devised to treat them. One such solution is rotationplasty, a unique surgical procedure used to treat a congenital defect or tumor of the leg.

Traditionally, treatment of severe congenital femoral deficiencies required a knee fusion with a Syme amputation, which includes disarticulation of the ankle (ie, amputation above the ankle joint) and a flap made with the skin of the heel. Often, tumors of the femur still are treated with high-level, above-the-knee amputation (AKA) requiring adjuncts to assist with ambulation. People with these types of amputations have an unnatural gait and expend increased energy because they lack an active, biological knee joint.

The importance of an active knee joint in the biomechanics of lower limb function has been demonstrated in multiple studies. (1-3) A below-the-knee amputation (BKA) is more functional and energy efficient, and consequently, results in a more natural appearing gait with the aid of a BKA prosthesis.

With rotationplasty, the surgical result is a leg shortened and rotated 180 degrees so the reversed ankle functions as a knee joint. The ankle plantar flexion simulates knee extension and ankle dorsiflexion simulates knee flexion, providing function similar to a BKA. The outcome is visually unusual but very functional for children who place a higher value on physical capabilities than appearance (Figure 1).

[FIGURE 1 OMITTED]

HISTORY OF ROTATIONPLASTY

Borggreve first described rotationplasty in Germany in 1927 for a 12-year-old patient whose knee was destroyed by tuberculosis. (4) He described a procedure in which the femur was shortened and the leg rotated 180 degrees so the foot faced posterior and the ankle functioned as a knee joint when fitted into a prosthesis.

Van Nes modified and popularized the procedure in 1950, reporting the results of rotationplasty in three patients with congenital femoral deficiencies. (5) In 1982, Kotz and Saltzer described the use of a modified version of a rotationplasty procedure to treat malignant tumors of the distal femur. (6) Torode and Gillespie provided further modifications for congenital femoral deformities in 1983 by combining a knee arthrodesis with partial rotation (ie, fusion of the knee joint by removing the articular surfaces and securing bony union) and a tibial rotational osteotomy through the mid shaft as originally described by Van Nes to address the tendency for distal derotation. (6) Krajbich modified Torode's and Gillespie's approach to achieve complete rotation through knee arthrodesis. (7) Although the procedure in tumor surgery was first developed for abnormalities of the distal femur, modifications of the Van Nes procedure now allow use of rotationplasty for lesions of the proximal femur and the proximal tibia. (8)

When the hip joint is involved, the procedure can be modified in several ways to create a functioning hip joint. If the femoral head and neck are involved, the proximal femur is resected, and the distal femur with its intact knee joint is rotated and secured to the acetabulum so the knee can provide hip flexion and extension and the ankle can function as the new knee joint (Figure 2). In 2000, Winkelmann described yet another modification of rotationplasty, a hip rotationplasty type B-IIIa. The hip rotationplasty is indicated when a tumor involves the entire femur or when skip lesions (ie, when the tumor has seeded to a second site in the bone) are present. (9) This modification involves resecting the entire femur, rotating the tibia-foot segment 180 degrees, then placing the lateral tibial plateau into the acetabulum. Over time, the tibial plateau remodels to become anatomically similar to a femoral head. (10)