This past spring I was asked to give a talk at an Extreme Affordability Conference in Global Heath Care. The tenor of the meeting was finding ways to bring the latest technologies to lesser developed countries to improve their health care outcomes. However, what I spoke on was exactly the opposite. What can we learn as a developed country from those with less technology at their disposal? It just took me one afternoon walking through the wards of Limpopo South Africa in 2005 to embrace what lesser developed countries had to offer western medicine. What I saw were numbers of beautiful children who had undergone rotationplasty playing basketball and football without limitation as they dealt with the nonorthoapedic challenges of osteosarcoma. In a US society where it is felt that the latest technology surely must be the best for our patients, it is rotationplasty that has endured decades of scrutiny and criticisms over cosmesis, while continually demonstrating excellent and durable functional results in children.1
In the growing child, there are obviously many challenges in managing a primary bone sarcoma. Not only is it a medically difficult time for a family, the diagnosis is emotionally devastating. It is overwhelming to think of one’s child in such agony and after a year of treatment there is, at best, a three out of four chance that one’s child may be alive at five years. Add to that the burden that if they do live, their salvaged limb will need to last them a lifetime. While in children over 10 years of age, endoprosthetics seem to have reasonable results, in younger children the challenges are greater.2 Presently, with the most advanced treatments available, children are out living their endoprostheses with what by any other standard would be considered an intolerable rate of complications and revisions at around half and a third, respectively.3,4 Authors conclude that “current technology does not offer a single best reconstructive option for children”.3 It is established that the better the function a child has heading into adulthood the happier they will be throughout life.5 With current endoprosthetic limb salvage in younger children, high rates of infection as well as significant loss of movement and function can compromise quality of life and adversely influence psychosocial issues.6 Presciently and prophetically, over 20 years ago, Postma et al7 pointed out that “quality of life in bone tumor patients is [negatively] affected by limb salvage as well as amputation”. In fact, limb salvage patients’ perception of quality of life may be no better than patients with above knee amputations.8
So what about techniques such as rotationplasty that predate modern endoprosthetics? Formally introduced in 1927 by Borggreve, the procedure has undergone much adaption to its present use in pediatric bone sarcoma surgery.9 Nonetheless, authors continue to find superior functional results about the knee compared with amputation and endoprosthetics.10 Furthermore, good to excellent results have been seen when used to salvage failed endoprosthetics.11,12
Having never seen a rotationplasty performed during all my years of western training, it took the internet to convince a teenager to let her mother give me permission to do my first one. The case involved an adolescent girl who had undergone a proximal femoral endoprosthetic limb salvage at an outside hospital at the age of…2! Having never walked without a brace and had multiple surgeries, she sought out options voraciously. Via the internet, she had seen videos and wanted to give it a try. Thanks to social media, similar stories are beginning to unfold throughout the growing global sarcoma virtual community. Now, children are leading their families though this new silicon world, earnestly searching for answers as to the best way to move forward functionally. In growing numbers, they are choosing rotationplasty as they communicate via social media with children and their families that have had either a rotationplasty (and infrequently have to see their orthopaedic oncologists again) or an endoprosthesis. Rotationplasty, a technique first described almost 85 years ago, is growing in popularity due to the meritocracy of social media technology. Having your foot put on backwards as your knee is even considered to be cool by some of the younger generation of sarcoma survivors.
R. Lor Randall, MD, FACS, The LB & Olive S. Young Endowed Chair for Cancer Research, Director, Sarcoma Services & Chief, SARC Lab, Medical Director, HCI Surgical Services, Professor of Orthopaedics, Huntsman Cancer Institute & Primary Children's Medical Center, The University of Utah, USA
1. Sawamura C, Hornicek FJ, Gebhardt MC. Complications and risk factors for failure of rotationplasty: review of 25 patients. Clin Orthop Relat Res 2008;466:1302-8.
2. Israelsen RB, Illum BE, Crabtree S, Randall RL, Jones KB. Extremity sarcoma surgery in younger children: ten years of patients ten years and under. Iowa Orthop J 2011;31:145-53.
3. Henderson ER, Pepper AM, Marulanda G, Binitie OT, Cheong D, Letson GD. Outcome of lower-limb preservation with an expandable endoprosthesis after bone tumor excision in children. J Bone Joint Surg [Am] 2012;94-A:537-47.
4. Ruggieri P, Mavrogenis AF, Pala E, Romantini M, Manfrini M, Mercuri M. Outcome of expandable prostheses in children. J Pediatr Orthop 2013;33:244-53.
5. Robert RS, Ottaviani G, Huh WW, Palla S, Jaffe N. Psychosocial and functional outcomes in long-term survivors of osteosarcoma: a comparison of limb-salvage surgery and amputation. Pediatr Blood Cancer 2010;54:990-9.
6. Ottoviani G, Robert RS, Huh WW, Jaffe N. in N. Jaffe (eds), Pediatric and Adolescent Sarcoma, Cancer Treatment and Research 152, DOI 10.1007/978-0284-9_23©Springer+Business Media, LLC 2009
7. Postma A, Kingma A, De Ruiter JH et al. Quality of life in bone tumor patients comparing limb salvage and amputation of the lower extremity. J Surg Oncol 1992;51:47-51.
8. Malek F, Somerson JS, Mitchel S, Williams RP. Does limb-salvage surgery offer patients better quality of life and functional capacity than amputation? Clin Orthop Relat Res 2012;470:2000-6.
9. Winkelmann WW. Type-B-IIIa hip rotationplasty: an alternative operation for the treatment of malignant tumors of the femur in early childhood. J Bone Joint Surg [Am] 2000;82-A:814-28.
10. Akahane T, Shimizu T, Isobe K, Yoshimura Y, Fujioka F, Kato H. Evaluation of postoperative general quality of life for patients with osteosarcoma around the knee joint. J Pediatr Orthop B 2007;16:269-72.
11. Hillmann A, Gosheger G, Hoffmann C, Ozaki T, Winkelmann W. Rotationplasty--surgical treatment modality after failed limb salvage procedure. Arch Orthop Trauma Surg 2000;120:555-8.
12. Wicart P, Mascard E, Missenard G, Dubousset J. Rotationplasty after failure of a knee prosthesis for a malignant tumour of the distal femur. J Bone Joint Surg [Br] 2002;84-B:865-9.