Rotationplasty, commonly known as a Van Nes rotation or Borggreve rotation

Rotationplasty is a surgery to amputate (remove) the middle part of your leg when there is a tumor near your knee. Your surgeon rotates the lower section of your leg (shin bone, ankle, and foot) 180 degrees. So, your foot points backwards. They reattach it to your remaining thigh bone. The ankle serves as a replacement knee joint. You wear a prosthesis (artificial limb) on your foot. Generally speaking, a rotationplasty leaves you with greater function than you would have with a standard amputation.

Rotationplasty is a very old concept. The original operation was the Van Nes rotationplasty. Newer modifications of this operation, first by Brown in 1996, and then by Paley in 1997, have made this an excellent alternative for the most severely deficient cases.

The Van Nes rotationplasty converts the ankle into a knee, and the knee is fused straight, and the hip is floating free. This type tends to rotate back partially, undoing the benefit of the rotationplasty; the Paley-modified Brown rotationplasty converts the knee into a hip and the ankle into a knee. The hip is very stable with this type because the small remnant of femur is fused to the pelvis. All of the original hip and knee muscles are reattached to operate the knee which becomes the new hip joint. The Paley rotationplasty connects the knee to the existing femoral head (when it is present) so that hip motion is produced by the combination of flexion of both knee and hip joints. Because the femoral head is connected, the hip can also abduct (move to the side) as well as rotate. This is not possible with the Brown rotationplasty. This gives a much better three-dimensional hip motion. The ankle again serves as the knee.

Procedure

In the actual procedure, the bone affected by the tumor, as well as a small part of the healthy femoral and occasionally tibia bone, is removed. A portion of the leg removed; the ankle joint is then turned 180 degrees and is reattached to the thigh. They are held together by plates and screws until they have healed naturally. The surgery can take anywhere from 6 to 10 hours, with a day or two in intensive care. The leg is kept in a cast for 6 to 12 weeks. After the leg has sufficiently healed, the leg can be fitted for a prosthetic.

People with knee tumors from osteosarcoma or Ewing sarcoma (types of bone cancer) may need rotationplasty. The procedure is more common in children and teenagers, since osteosarcoma mostly affects this age group. Children and teenagers are also better candidates for rotationplasty because their bones are still growing. Their reattached leg continues to grow as they grow, so they can adapt to more activities.

In some cases, children and adults with the following conditions may need rotationplasty:

Congenital (present at birth) leg deformities.
Knee infections due to prostheses.
Traumatic leg injuries.

The risks of rotationplasty

The biggest risks immediately after surgery include:

Arterial occlusion (reduced blood flow).
Deep vein thrombosis (DVT) (blood clot in your leg).
Edema (swelling due to fluid buildup in the body).
Postoperative bleeding.
Venous insufficiency (pooled blood in the leg veins).

Complications that can occur during the healing process or long after surgery may include:

Infections or problems with wound healing.
Leg bone fractures.
Problems from the prosthesis, such as sores or nerve damage.
Slipped capital femoral epiphysis (hip joint misalignment).
Thigh and shin-bones don’t fuse together.

The benefits of rotationplasty

Rotationplasty offers several advantages over other procedures, including:

Less risk of phantom limb pain (pain where a limb used to be).
More leg mobility since the ankle functions as a knee joint.
Better leg stability because the foot and toes naturally bear weight and provide balance.
Continued bone growth. In children, the reattached bones continue to grow as they grow. A healthcare provider adjusts the prosthesis as they mature.