Rotationplasty is an orthopedic procedure involving the rearrangement of a limb segment to preserve function after removing a diseased section. This biologic reconstruction creates a functional joint from a part of the limb that would otherwise be discarded. While visually unusual, the procedure is a successful method of limb salvage, offering high mobility and long-term durability, especially for young patients with bone tumors near the knee. The operation transforms the lower leg and foot into a dynamic stump that significantly improves the patient’s interaction with a prosthetic limb.
The Origins of Rotationplasty: Key Pioneers and Historical Context
The initial concept for rotationplasty dates back to the early 20th century, emerging from the need to treat infections and trauma that destroyed the knee joint. The procedure was first described and performed by the German surgeon Joseph Borggreve in 1930, although some sources place his initial work in 1927. Borggreve used the technique on a patient whose knee was damaged by tuberculosis, demonstrating that a rotated foot could effectively replace a non-functional knee joint.
Despite Borggreve’s pioneering work, the procedure did not gain widespread recognition until two decades later. The technique was subsequently popularized by Dutch orthopedic surgeon Cornelis Pieter van Nes, who published his results in 1950. Van Nes specifically applied and refined the procedure for the management of congenital femoral deficiencies. The procedure became known as the Borggreve-Van Nes rotationplasty, establishing a foundation for its later application in oncology.
The modern application of rotationplasty as a primary oncologic treatment came much later. The first reported use of the technique for malignant tumors, specifically osteosarcoma, was by Salzer and colleagues in Vienna in 1981. This shift established rotationplasty as a viable alternative to high-level amputation for patients, most often children, who required the complete removal of the tumor-ridden knee joint and surrounding bone. The procedure offered a method to achieve clean surgical margins.
Surgical Mechanics: How the 180-Degree Rotation Functions
Rotationplasty is a surgical intervention centered on the precise removal and reattachment of a limb segment. The process begins with removing the diseased section, typically including the distal femur, the entire knee joint, and the proximal tibia. The surgeon must ensure all cancerous tissue is removed with clear margins while carefully preserving the neurovascular bundle, particularly the sciatic nerve and femoral artery.
Once the tumor-bearing segment is resected, the remaining lower limb segment (tibia, ankle, and foot) is rotated 180 degrees on its longitudinal axis. This rotation causes the foot to face backward, with the toes pointing away from the body’s midline. The rotated ankle joint is then surgically fixed to the remaining healthy portion of the upper femur.
The anatomical reason for the 180-degree rotation is to convert the ankle’s natural dorsiflexion and plantarflexion motions into a functional knee bend. The ankle joint, which naturally bends in the opposite direction of the knee, now bends forward relative to the body, mimicking the movement of a knee. The heel and ankle joint are positioned to fit into a specialized below-knee prosthesis. This allows the patient to voluntarily control the prosthetic limb’s movement by flexing and extending the ankle, ensuring the foot acts like a dynamic, controllable stump.
Modern Indications and Patient Functional Outcomes
Today, rotationplasty is primarily indicated for skeletally immature patients, typically children and adolescents, with malignant bone tumors like osteosarcoma or Ewing sarcoma located around the knee joint. The procedure is often preferred over limb-sparing operations using endoprostheses because the patient’s bone continues to grow. Furthermore, the reconstruction is durable and biologic, avoiding complications such as implant loosening or the need for multiple revision surgeries common with artificial joints.
The functional outcomes following rotationplasty are consistently high, often surpassing those achieved with high-level above-knee amputation. Preserving the sciatic nerve and the ankle joint provides superior proprioception, which is the body’s sense of position and movement. This retained sensation allows patients to have a more coordinated and energy-efficient gait pattern, similar to those achieved with a below-knee amputation.
Patients who undergo rotationplasty often achieve high levels of physical activity, including running, cycling, skiing, and participating in competitive sports. Studies comparing rotationplasty patients to those with other limb salvage techniques report equivalent functional scores and better long-term quality of life. While the rotated appearance is unusual, patients generally adapt well, and emotional acceptance and social functioning are reported to be high. Rehabilitation typically involves casting followed by specialized physical therapy to learn how to actively use the rotated ankle joint to manipulate the new prosthesis.