Rotationplasty

Nathan Dugan3rd Year PT StudentColumbia University

http://www.hindawi.com/journals/sarcoma/2008/402378/fig4/

Objectives• Explain what rotationplasty is and how it is

performed• Discuss rehabilitation options for rotationplasty• Discuss prosthetics relating to rotationplasty• Review outcome measures that may be beneficial

to administer in this population• Present conclusions drawn during the course of

compiling this presentation related to research and outcomes in rotationplasty

Background Information

What is Rotationplasty?

• Biologic reconstructive option for congenital and acquired lower extremity bone loss• Indicated for: • Proximal femoral focal deficiency (PFFD) • Sarcomas of hip, femur, proximal tibia• Failed limb salvage procedures, failed THA/TKA• Traumatic bone loss• Severe burns with intact distal limb

Gupta 2012

Types of Rotationplasty

• Type A• ankle joint functions as knee joint

• Type B• knee joint functions as hip joint, ankle joint

functions as new knee joint

Gupta 2012

Type A Rotationplasty

• Type AI • distal femoral

resection • Type AII• proximal tibial

resection

Gupta 2012

Type B Rotationplasty

• Type BI• proximal femoral

conditions with no hip involvement

• Type BII• performed in the

setting of hip joint or lower pelvis involvement

Gupta 2012

Type B Rotationplasty

• Type BIII• performed when complete resection of the

femur is necessary

• Type BIIIa• lateral condyle of the tibia is placed into the

acetabulum (expected to remodel)

• Type BIIIb• tibia is rotated and connected to pelvis with

endoprosthesis

Gupta 2012

Type B Rotationplasty

• Type BIIIa • Type BIIIb

Gupta 2012

Relevant Anatomy

Gupta 2012

Rehabilitation

Rehabilitation Course: General Guidelines

• Gentle PROM of the ankle and AROM/antigravity movements of hip important early-on in process• Want to avoid hip flexion/adduction contractures,

similar to AKA

• Functional training with assistive devices• Progress to AROM of ankle/toes• Resisted exercise typically begins 6-12 weeks post-op,

when soft tissue healing is complete

• Advance to weight-bearing once there is evidence of healing at osteotomy site

Gupta 2012, So 2014

Rehabilitation Course: Considerations

• Full weight-bearing is not allowed until osteotomy site is fully healed

• AROM 0-30 degrees is needed to operate knee in prosthesis (optimal PF/KE is 50 degrees)

• Be mindful of pain post-operatively

Gupta 2012, So 2014

Rehabilitation: Case Study

Prosthetics

Rehabilitation Course: Prostheses

• Retrospective observational study with n=12

• Median age: 10 years (5-13 yrs), 8 males• All patients had oncologic pathology• Osteosarcoma (10), synovial sarcoma (2)

So 2014

Rehabilitation Course: Prostheses

• Preliminary bypass prosthesis• Allows TTWB without shearing at osteotomy

site• Bypasses “knee” joint• No “knee” flexion through prosthesis

• Must use assistive device to ambulate• Components:• Polypropylene, ischial WB, quadrilateral sockets• Total elastic auxiliary suspension• Pylon and Seattle LightFoot

So 2014

Preliminary Bypass Prosthesis

So 2014

Rehabilitation Course: Prostheses

• Definitive prosthesis• Acrylic laminate socket with polypropylene

thigh section• Anatomic suspension• Calcaneal strap• Removable calcaneal wedge

• Seattle LightFoot

So 2014

First Definitive Prosthesis

So 2014

How Long Did it Take?

• In 10 patients requiring chemotherapy• 230.5 days

• In 2 patient not requiring chemotherapy• 78.5 days

• Time between first and second prosthesis• 18.5 months

So 2014

Considerations for Prostheses

• Stops for ankle (“knee”) flex/ext• Compensates for patient’s inability to control knee

flexion moment at heel strike

• Use longest foot that can fit in shoe• Provides a longer lever arm, assists in knee stability

• Subsequent prostheses can incorporate carbon fiber dynamic response/multiaxial foot options

• Allow for easy adjustments to compensate for growth

So 2014

Innovation in Prosthetics

• In cycling, thigh cuff of a conventional prosthesis leads to perspiration, chaffing, and skin abrasion

• Case of an 18 y/o male cyclist with rotationplasty• He regularly contracted abrasion injuries at

foot/thigh• Only able to cycle 35km (21.7mi)

Scheepers 2015

Cycling Specific Prosthesis Design

Scheepers 2015

Cycling Specific Prosthesis Design

Scheepers 2015

Outcome Measures

Outcomes Assessment

• FMA (functional motor assessment), MSTS (musculoskeletal tumor society) rating scale, Toronto Extremity salvage score (TESS)

• SF-36v2• Gait analysis, TUG, 6MWT, ROM, MMT, etc.

Functional Motor Assessment (FMA)

• Six subcategories:• Pain• Function with two specific measures• Timed up-and-down 12 stairs (TUDS)• Timed up-and-go (TUG)

• Supports• Satisfaction with walking quality• Participation in work, school, sports• Endurance• 9-minute walk-run test

Marchese 2007

Musculoskeletal Tumor Society (MSTS) Rating Scale• Also known as Enneking Score• Examines 6 factors• Pain• Functional activities• Emotional acceptance• Use of supports• Walking ability• Gait

Enneking 1993

Toronto Extremity Salvage Score (TESS)

• Disease-specific measure developed for patients undergoing limb preservation surgery for tumors of the extremities

• Evaluates physical disability based on patients’ reports of their function

• 29-item lower extremity and 28-item upper extremity questionnaire

• Items rated on 5-point scale from “not at all difficult” to “impossible to do”• Importance of each item is rated on 4-point scale from

“totally unimportant” to “extremely important”

Davis 1996

Conclusions

An Overall Paucity of Research

• Search on PubMed for “rotationplasty” yields only 154 results since 1962• Only 2.9 articles per year

• Overall quality of research is low• Results yield many case studies/case series and few, if

any, RCTs

• Virtually no mention of rehabilitation in the research• At best, a few sentences within other studies mentioning

generalities• Research is concentrated in the areas of surgical

techniques/complications, quality of life, and function

Highly Functional Individuals

• Individuals have been shown to be highly functional post-rotationplasty• Hillman 2007, Harris 2013

• Individuals often score highly on quality of life measures• Forni 2012, Barrera 2012, Rödl 2002

https://www.youtube.com/watch?v=g28tS68dagM; http://www.rotationplasty.com/Sean-Dever

Questions?

References1. Gupta SK, Alassaf N, Harrop AR, Kiefer GN. Principles of rotationplasty. J Am Acad Orthop Surg 2012;20:657-667.2. So NF, Andrews KL, Anderson K, et al. Prosthetic fitting after rotationplasty of the knee. Am J Phys Med Rehabil

2014;93:328-334.3. Scheepers LG, Storcken JO, Rings F, et al. New socket-less prosthesis concept facilitating comfortable and abrasion-

free cycling after Van Nes rotationplasty. Prosthet Orthot Int 2015;39(2):161-165. 4. Davis AM, Wright JG, Williams JI, et al. Development of a measure of physical function for patients with bone and

soft tissue sarcoma. Qual Life Res 1996;5:508-5165. Marchese VG, Rai SN, Carlson CA, et al. Assessing functional mobility in survivors of lower-extremity sarcoma:

reliability and validity of a new assessment tool. Pediatr Blood Cancer 2007;49:183-189.6. Enneking WF, Dunham W, Gebhardt MC, et al. A system for the functional evaluation of reconstructive procedures

after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat R 1993;286:241-246.7. Hillman A, Weist R, Fromme A, et al. Sports activities and endurance capacity of bone tumor patients after

rotationplasty. Arch Phys Med Rehabil 2007;88(7):885-890.8. Harris JD, Trinh TQ, Scharschmidt TJ, Mayerson JL. Exceptional functional recovery and return to high-impact sports

after Van Nes Rotationplasty. Orthopedics 2013;36(1):126-131.9. Forni C, Gaudenzi N, Zoli M, et al. Living with rotationplasty – quality of life in rotationplasty patients from childhood

to adulthood. J Surg Oncol 2012;105(4):331-336.10. Barrera M, Teall T, Barr R, et al. Health related quality of life in adolescent and young adult survivors of lower

extremity bone tumors. Pediatr Blood Cancer 2012;58(2):265-273.11. Rödl RW, Pohlmann U, Gosheger G, et al. Rotationplasty – quality of life after 10 years in 22 patients. Acta Orthop

Scand 2002;73(1):85-88.