Maya Oberstein was diagnosed with osteosarcoma of the distal femur in 2012, at age 9. After she completed chemotherapy, Maya’s treatment options were an above-knee amputation, limb salvage with an internal prosthesis or a more unconventional approach: rotationplasty. Carol Morris, chief of Johns Hopkins’ Orthopaedic Oncology Division, is one of a select group of surgeons in the United States who perform this alternative reconstructive procedure. Morris counseled Maya and her family on the available options. “She was the first doctor who asked me how I was feeling,” says Maya, “how I was doing.”
Developed in 1930 to treat femoral deficiency in a patient with tuberculosis, rotationplasty today may be indicated for lower-extremity bone sarcoma. The procedure involves resecting the knee while retaining the femoral artery and sciatic nerve. The distal segment is rotated 180 degrees and reattached to the proximal segment, converting the reversed ankle joint into a functional knee joint. The foot acts as a tibia, fitting into a modified transtibial prosthesis.
Rotationplasty presents unique challenges that Morris considers when preparing for the procedure. In younger patients, she says, “you have to calculate how much growth they have left in the foot and in the ankle of that side so when they’re done growing, the heel matches the level of the knee on the other side. Cosmetically, if you’re sitting, it’s nice if the knees are even.”
Morris recalls her initial reluctance about the procedure. “I thought it was a physically challenging thing to do to a child when prosthetics had made tremendous advancements,” she says. “As I gained more experience in the field, I began to appreciate the limitations of internal prostheses and the functionality rotationplasty could provide. For the right parents and the right child, under the right set of circumstances, rotationplasty is a good operation. It’s much more functional than an above-knee amputation.”
Traditional prostheses, especially growing protheses, are more restrictive than the modified transtibial prosthesis, limiting a patient’s ability to participate not only in sports, but in typical activities such as running, dancing and jumping.
“It’s a great option for patients with cancer around the knee. It’s great for kids who want to be very athletic. It’s even great for adults who want to maintain a high level of function,” says Morris. Although there is concern that the cosmetic issue could affect quality of life, Morris says patients who choose rotationplasty “turn out to be some of my happiest patients.”