“Rotationplasty” – A Hope for Young Kids with Lower Limb Bone Cancers

At a young age of 5 or 7, when most kids are busy playing kickball or building blanket forts, Atharv Tiwari (5 years old at the time of surgery) and Mohammad Irfan (7 years old at the time of surgery), we're dealing with the most difficult times of their lives. At that age when they might not possibly be aware of what cancer is, they were victims to one of the rarest types of cancer, known as osteosarcoma. It was unfortunate because the available treatment meant amputation of the affected portion or removal of tumour and implantation of the metallic prosthesis. The tender age of the kids was one of the biggest hurdles because both these treatment options could either restrict their growth or make them dependent on others for a lifetime. For parents, after their initial shock, it was a search for alternate treatment options which brought them to Max Super Speciality Hospital, Saket. They were introduced to an entirely different technique of limb salvaging called Rotationplasty, something that the parents had never heard of. Although it is a well-described surgery, rotationplasty performed very rarely, because of a lack of awareness of the benefits of this surgery and the lack of surgical expertise required for this complex surgery.

Atharv had the sarcoma at the upper femur, near the hip joint measuring 9X3 cm, while Md Irfan had a 10 cm tumour, near the knee. After understanding the condition of their children from the doctors and available treatment options, both the families could only rely on Rotationplasty to save their children and retain their limb functionality as they grew up. Irfan who had undergone chemotherapy at his hometown in Bihar before coming to Max Healthcare, Saket, was 7 years 3 months old when he underwent the surgery. As Atharv was just 5 and arrived with bigger complexity due to the location of his sarcoma (near the hip joint), challenges with his function were much greater as compared to rotationplasty around the knee. At such a young age theses children underwent a rare and complicated rotationplasty surgery. 

In rotationplasty, the segment of a limb with the disease is cut and only the artery, vein and nerve is preserved. The remaining lower leg is rotated backwards and joined with the thigh using plates, screws on the bones. The limb is rotated because the ankle flexes in the opposite direction compared to the knee. In this way, the ankle comes at the same level as the opposite knee and the patient is gradually trained with physiotherapy to use this ankle as the new knee. The patient wears a prosthetic leg below this, and the above-knee amputation is converted into a below-knee amputation with excellent functional outcome.

Rotationplasty is a functional surgical procedure for children undergoing resection of a malignant bone tumour where after removing the part of the limb affected by cancer, the lower part remains connected to the upper part with only the nerves and the vessels. The distal limb is joined to the upper limb, but only after rotating it 180 degrees, so that the foot now faces backwards. The ankle of the child now acts as the knee, and the child now needs a “below knee prosthesis” rather than an “above knee prosthesis”. As the ankle is deliberately kept at a level lower than the knee of the opposite leg, it reaches the level of the opposite knee at the end of growth, thereby taking care of the limb length discrepancy as well. It is a rare procedure performed only at a specialised centre dealing with bone cancer patients and produces good results properly selected patients. Unlike amputation and limb, salvage rotationplasty is a durable one-time solution, affordable, will lead to equal limb lengths at the end of growth, and with an excellent function of the limb. 

Talking about these cases, Dr Akshay Tiwari, Associate Director & Head - Musculoskeletal Oncology, Max Super Speciality Hospital, Saket, “One of the key advantage of rotationplasty compared to other surgical options is that it allows the child to have a complete active lifestyle. With limb-salvage surgery or full amputation, the child wouldn’t have been able to do high impact sports or jumping. These kids Atharv and Irfan, who have their entire life yet to begin rotationplasty saves them from physical as well as mental trauma that other processes like amputation can bring along. With rotationplasty, they will be able to participate in sports, which may include running,  baseball and cricket..,. Even sports where knee motion is important – such as bicycling, skiing, or horseback riding – are possible after this procedure. With rotationplasty, the complication rate is low, and there is no phantom pain since the nerves are not cut for this procedure. At last, I would just wish these kids for a healthier life.”

Present at the event Dr Ramandeep Singh Arora, Principal Consultant, Pediatric Oncology, Max Super Speciality Hospital, Saket, shared his insights on children’s cancer cases in India. He said “It is unfortunate to see children at such a young age dealing with devastating health problems like cancer. If picked up early, these cancers are curable. Though the incidence rate of cancer in India among children is approximately 3%, yet appropriate medical facilities are not available everywhere. Rotationplasty is one such surgical method that is selectively done at few centres, is an extremely useful procedure that gives a long-lasting, good functional limb to these children. These children here can lead a life at par with any normal individual, without hindering their growth or mobility in the long term.” 

Both the kids Atharv and Irfan recovered well and have been actively participating in sports like children around them. Irfan’s surgery was funded by CanKids, an NGO actively working with kids diagnosed with cancers.