Rotationplasty: Procedure, Benefits, Risks, Recovery and Alternatives

Rotationplasty, sometimes called Borggreve-Van Nes rotationplasty, is a distinctive surgical procedure most often used as a limb-salvage technique for children and young adults with bone tumors near the knee. While its “backward foot” appearance can be startling, this innovative approach offers remarkable function and quality of life for selected patients. In this comprehensive article, we’ll explore how rotationplasty is performed, its benefits and risks, what recovery looks like, and how it compares to alternative treatments.

Rotationplasty: The Procedure

Rotationplasty is a reconstructive operation that removes a diseased segment of the lower limb—most commonly the knee and adjacent bone—then rotates the lower leg 180 degrees and reattaches it. This positions the ankle where the knee once was, allowing it to function as a new knee joint when fitted with a below-knee prosthesis. The procedure is most commonly performed for pediatric bone sarcomas, but it can also be used for severe trauma, congenital deficiencies, or as a salvage after failed limb-sparing surgeries in both children and adults.

Indication	Key Step	Limb Function	Source
Bone tumor (knee)	Segment resect	Ankle as knee	4 5 10
Failed limb salvage	180° rotation	Active knee motion	1 18
Congenital deficiency	Reattach limb	Prosthesis ready	13 14

Table 1: Rotationplasty Procedure Summary

Indications and Patient Selection

Rotationplasty is most often used for:

• Malignant bone tumors around the knee (distal femur or proximal tibia) in children and young adults
• Failed limb salvage procedures due to infection, tumor recurrence, or prosthesis failure
• Severe congenital femoral deficiency (CFD)
• Select cases of non-union or chronic infection where amputation would otherwise be required 1 4 5 13 14

A key technical requirement is the preservation of the sciatic nerve and adequate vascular supply to the foot, as the lower leg must remain alive and functional after rotation and reattachment 5 11 12.

Surgical Technique

• After resection of the affected bone and surrounding tissues, the lower leg is rotated 180 degrees. This allows the ankle joint to mimic the knee’s function, with the foot now facing backwards.
• The rotated limb is fixed (usually with plates or intramedullary rods) to the remaining femur or pelvis, depending on the level of resection 4 5.
• Care is taken to preserve nerves and blood vessels; sometimes, vascular anastomosis (reattachment) is required, especially after multiple prior surgeries 11 12.
• In children, the predicted remaining bone growth must be considered, as the new limb will no longer grow in the same way as the original 5 3.

Prosthesis and Limb Function

The patient is fitted with a custom below-knee prosthesis, allowing the rotated ankle joint to provide active knee-like movement. This approach enables walking, running, and even participation in sports, offering function similar to a below-knee amputation rather than an above-knee amputation 4 7 15.

Benefits and Effectiveness of Rotationplasty

Rotationplasty’s unique design offers functional and psychological benefits that set it apart from both amputation and prosthetic limb replacement, especially in young and active individuals.

Outcome	Functional Level	Notable Benefit	Source
Mobility	Below-knee level	Active knee control	4 7 9
Sports	High participation	Reduced energy expenditure	6 9 16
Quality of life	High	Less pain, more activities	6 9 15

Table 2: Rotationplasty Benefits Overview

Superior Functional Outcomes

• Rotationplasty allows for an active, controlled knee joint (via the ankle), providing a gait similar to able-bodied individuals and superior to above-knee amputation 7 15 17.
• Patients typically achieve independent walking, often without assistive devices 6 7.
• Energy expenditure is lower than with above-knee amputation (similar to below-knee amputation), making everyday activities and sports more accessible 15 16.

Quality of Life and Participation

• Studies show patients with rotationplasty have similar or even better quality of life scores compared to those with endoprosthetic replacements, especially in physical activity, social participation, and pain reduction 6 9 15.
• Many patients return to high-level sports and recreational activities, sometimes at competitive levels 9 16.
• Rotationplasty avoids phantom limb pain and the proprioceptive loss often seen with traditional amputations because nerves and muscles are largely preserved 15 18.

Durability and Fewer Revisions

• Unlike endoprosthetic replacements, rotationplasty is a biological reconstruction that rarely requires revision surgery, making it especially advantageous for younger patients who would otherwise outgrow prosthetic implants 6 9 15.

Psychosocial Adaptation

• Despite initial concerns about limb appearance, long-term studies show high satisfaction and psychosocial well-being among most patients, particularly when well-supported during decision-making 15 16.

Risks and Side Effects of Rotationplasty

As with any major surgery, rotationplasty carries risks. While most patients do well, complications can occur both immediately after surgery and in the long term.

Complication	Frequency	Impact	Source
Vascular issues	Occasional	May require amputation	10 11
Wound problems	Moderate	May need debridement	12 13
Nerve injury	Rare	Usually transient	10
Psychosocial	Variable	Adjustment challenges	15 14

Table 3: Rotationplasty Risks and Side Effects

Surgical and Early Postoperative Risks

• Vascular Complications: Compromised blood flow (due to vessel damage or thrombosis) can sometimes necessitate amputation; this risk is higher in patients with prior multiple surgeries or infections 1 10 11 12.
• Wound Healing Problems: Wound necrosis or dehiscence is relatively common and may require additional surgical interventions (e.g., debridement, skin grafting) 12 13.
• Nerve Injury: Both transient and permanent nerve palsies have been reported, though most resolve or are manageable 10 13.

Late Complications

• Bone Healing Issues: Delayed union, pseudarthrosis, and occasional fractures can occur and may require further surgery 10 12.
• Infection: Late infections are less common but can threaten the success of the procedure 10 13.
• Malrotation or Limb Length Discrepancy: Some patients may require revision surgery to correct malalignment or adjust limb length, especially in growing children 5 12.

Psychosocial and Cosmetic Concerns

• The “chimeric” appearance of the rotated limb can be a source of psychological stress or social anxiety, especially for adolescents and young adults. Some report difficulty with social or intimate relationships 14 15.
• However, with appropriate counseling and peer support, most patients adapt well and report high satisfaction in the long term 15 18.

Factors Affecting Risk

• Multiple prior surgeries, preoperative infections, or poor response to chemotherapy increase the risk of complications and failure 1 11 12.
• Elderly patients may have poorer functional results but can still benefit compared to above-knee amputation 19.

Recovery and Aftercare of Rotationplasty

Recovery from rotationplasty is intensive but rewarding, with the ultimate goal of restoring independence, mobility, and quality of life.

Recovery Phase	Focus Areas	Support Required	Source
Early rehab	Wound care, mobility	Physiotherapy, monitoring	10 13
Prosthesis fit	Customization	Prosthetist, training	5 7 15
Long term	Activity, sports	Ongoing PT, peer support	9 16

Table 4: Recovery and Aftercare Stages

Immediate Postoperative Care

• Hospital stay typically includes careful monitoring of the surgical site, vascular supply, and wound healing 10 13.
• Early physiotherapy focuses on maintaining joint range of motion, muscle strength, and adapting to the new limb orientation 13 15.

Prosthetic Fitting and Gait Training

• Once healing is adequate, a custom below-knee prosthesis is fitted. The prosthesis is tailored to the unique anatomy of the rotated limb 5 7.
• Gait training with physical therapists is essential, teaching patients to use their ankle as a new knee joint. This phase can take several months but yields excellent long-term mobility 7 15 16.

Rehabilitation Goals

• Full weight-bearing is usually achieved within a few months, with progressive return to daily activities and sports 9 16.
• Ongoing support may include psychological counseling, peer group meetings, and regular follow-up with the surgical and prosthetic teams 15 18.

Long-Term Outcomes

• Most patients are able to live independently, participate in sports, and report high satisfaction with their level of function 9 16.
• Regular follow-up helps monitor for late complications and ensure optimal prosthetic fit as the patient grows or ages 7 9.

Alternatives of Rotationplasty

While rotationplasty offers many advantages, it is not suitable for everyone. Several other surgical options exist for treating malignant or non-malignant lower limb conditions.

Alternative	Key Advantage	Limitation	Source
Endoprosthesis	Normal appearance	Multiple revisions	6 15
Allograft/autograft	Preserves limb	Risk of failure	15
Above-knee amputation	Simpler surgery	Higher energy, less function	4 6 15
Arthrodesis	Stability	No knee motion	15

Table 5: Alternatives to Rotationplasty

Endoprosthetic Replacement

• Involves implanting a metal prosthesis after tumor resection, preserving limb length and appearance 6 15.
• Functional outcomes are similar to rotationplasty, but risk of mechanical failure or need for multiple revisions is higher, especially in growing children 6 15.
• More likely to restrict participation in high-impact sports and may require assistive devices more often 6 15.

Allograft or Autograft Reconstruction

• Uses donor or patient’s own bone to reconstruct the limb after tumor removal 15.
• Risks include graft failure, infection, and non-union, often requiring further surgeries 15.

Above-Knee Amputation

• Removes the limb above the knee. This is a reliable and widely available option 4 6 15.
• Results in higher energy expenditure for walking, reduced function, and increased risk of phantom limb pain and proprioceptive loss compared to rotationplasty 4 15 18.

Arthrodesis (Joint Fusion)

• Offers joint stability but eliminates motion at the fused joint, limiting mobility and function 15.

Patient-Centered Decision Making

• Choice of treatment must consider age, tumor characteristics, prior surgeries, expected lifespan, and patient/family preferences 15.
• Psychosocial support, including meeting others with similar experiences, is crucial to help patients and families make informed decisions 15 18.

Conclusion

Rotationplasty stands out as a functional, durable, and life-changing limb-salvage procedure for select patients facing bone cancer, failed reconstructions, or severe congenital limb deficiencies. While the cosmetic result requires adaptation, the functional rewards are significant. Here are the key takeaways:

• Rotationplasty replaces the knee with the ankle (rotated 180°) to create a new, functional knee joint while preserving active movement and sensation.
• It provides superior mobility and participation in daily activities and sports compared to above-knee amputation, with lower energy requirements and fewer revisions than endoprosthetic implants.
• Risks include vascular compromise, wound healing problems, and psychosocial challenges. Proper patient selection, surgical expertise, and postoperative support are essential.
• Recovery involves intensive rehabilitation, prosthesis fitting, and psychological support, resulting in high satisfaction and independence for most patients.
• Alternatives such as endoprosthesis, amputation, and allograft each have their place, but may not match rotationplasty’s unique combination of function and longevity—especially for young, active individuals.

Rotationplasty is an exemplary case where innovative surgical thinking and patient-centered care combine to restore not just limbs, but lives.