Rotationplasty

Originally there was just one type of Rotationplasty for PFFD. The Van Ness Rotationplasty.

Recently (2008) because of problems due to de-rotation with the Van Ness they have looked into fixing the femur permanently to the hip (Brown) or also in the surgery cutting and re-positioning the muscles.

History: The operation was originally performed by Dr. J. Borggreve in Germany in the 1930's on an adult patient. He removed the infected part of a femur, rotated the remaining part of the femur 180 degrees and re-attached it with the ankle now acting as a knee.

Van Nes applied it to PFFD patients in 1950. The procedure rotated the foot 180 degrees so that the ankle joint now functions as a knee joint. The rotated foot becomes the below-knee stump for the below-knee prosthesis.

There are two general methods for rotating the leg in children with PFFD. 1) At the proximal end of the femur and 2) at the knee or proximal tibia. Since in a younger child there is a lot of muscle and fat at thigh area, it makes rotation about the femur difficult for the surgeon10. If the procedure is performed by rotating through the knee or tibia it is easier on the surgeon however it requires twisting of the muscles that power the ankle around the tibia.

When the surgical rotation is done at or below the knee, the muscles are twisted around the bone because the muscles that power the ankle originate on the proximal (part closest to the body) tibia and fibula and distal (part closest to the foot) aspects of the femur. As the child grows and uses their ankle, the muscles' twisting power commonly causes de-rotations. If this occurs, it may require multiple surgeries to re-rotate the limb (see below for averages).

Prosthetics with a Van Ness: A prosthetic fitting is difficult, and it requires the the services of a skilled prosthetist.5 In 1983, Torode and Gillespie outlined their technique of combined knee fusion and tibia rotation.

Prerequisites: The main prerequisites for the Van Nes procedure include a normal foot, presence of the fibula, a stable hip, unilateral involvement, and an active range of motion of the ankle of at least 45 degrees.6 A stable hip improves the gait but is not an absolute prerequisite to the Van Nes procedure.6

For the Brown method - a stable hip is NOT required since the hip is fused.

There appears to be no concensus on the value and success rate for Van Nes Rotation. The two main concerns appear to be the poor cosmesis and derotation.

Different studies give different results. What we can do here is list the results here and let the reader decide for themselves. But as a final word as a parent I would ask ask the surgeon 1) where they plan to do the rotation (tibia, knee, femur, and if on the femur then 2) where on the femur relative to the muscle attachments that power the ankle).

Dr. Van Nes, 1950: Patients are very satisfied and grateful for the
aesthetic, functional and social improvements they have gained.6

Dr. Ivan Krajbich, 1991:
(describing an alternative to amputation):

The operation is extremely useful to convert what would be a functional above-knee amputee to functional near below knee amputee. The Van Nes rotation-plasty is functionally beneficial to the patient as it gives the child a knee that has active extension and flexion and significantly improves the biomechanics of gait. We still recommend it for children who have an adequate foot and ankle....

The primary drawback to this operation has been said to be its poor cosmesis and hence poor psychological acceptance by the patient. This has not been our experience. The operation is well accepted by patients and their families if one explains the benefits. The second objection to rotation-plasty is that it has a tendency to derotate and thus the operation has to be repeated one or two times during the child's growth. This is a
valid observation, and many of our patients did, indeed, require a second procedure to correct gradual derotation. In the last few years we have concentrated on accomplishing the rotation completely through the knee joint at the time of knee fusion and with reattachment of all muscles crossing the knee joint. Results of patients treated with this approach have so far been satisfactory with not a single patient requiring further derotation. Follow up, however, is still short term and final evaluation of these patients is not available.
[Krajbich, 1991]

Drs. Westin and Gunderson:

In our group of cases, only two of the eight patients so treated can be classified as successful.

Two cases were complete failures, necessitating return to the original position. The other four patients failed to gain full rotation. The cosmetic deformity of a foot pointing the wrong way could be distressing to some patients, especially girls. This, together with the prolonged treatment time, may outweigh the functional advantage.[Westin, 1969]

Drs. Friscia, Moseley, and Oppenheim, 1989:

Thirteen patients who had PFFD and were treated with a Van Nes procedure were evaluated at an average of five years after operation. Five patients needed a repeat rotation of the tibia: four because the limb had spontaneously derotated toward the original position and one because the limb had had insufficient rotation at the time of operation. The overall results were excellent in six patients, good in four, fair in one, and poor in one. One patient was excluded because they converted to a Syme amputation, due to the mother's inability to accept the cosmetic deformity. The number of operations related to the rotationplasty,
including the initial procedure, ranged from one to five (average, three operations for each patient). Some authors have advocated amputation of the toes of the rotated foot to make the deformity more acceptable to the patient and the family; however, none none of our patients wanted to have the toes amputated to improve the appearence of the extremity.

Psychological preparation is is essential for both the patient and the parents. The case of the patient who had had conversion to a Syme amputation for psychological reasons emphasizes that selection of the patients and preparation of the family is important. Early operation seems to provide for better emotional acceptance.

The girls and boys were equally satisfied with the result. The five girls who had an excellent result had no objection to the cosmetic appearance. Our study is in agreement with others in that, perhaps surprisingly, none of the patients who completed the surgical program were dissatisfied with the cosmetic result, including the girls. Therefore, male gender need not be a criterion for the procedure.6

Finally, my (Mike Malloy's) personal opinions: My wife and I were split on this issue. I felt that since our daughter had a perfectly good foot and ankle, we should try to use them to improve her walking ability. I saw the benefits of the Van Nes procedure, and felt a 'real knee joint' (even if it is a backward ankle joint) would be better than any artificial knee joint. Plus, I just hated the thought of amputating a perfectly good foot. (My wife says I just can't throw anything away.) On the other hand, my wife felt very strongly that the backward foot would be a severe cosmetic problem. For a boy she said she could possibly accept it, but for a girl she said no way. I was not yet prepared for a stump, but I had to agree with her that a backward foot would be much harder to accept. In the end my wife prevailed and I have no regrets.