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Advancing Limb Salvage Surgery: Reverse Foot Amputation

Reverse foot amputation, or rotationplasty, is a surgical technique offering hope to lower limb bone cancer patients. This blog outlines the procedure’s innovative approach to saving limbs and improving mobility, focusing on candidacy and rehabilitation.

Understanding Reverse Foot Amputation

Rotationplasty, colloquially known as reverse foot amputation, is a pioneering limb-salvaging surgical procedure that stands as a beacon of hope for many patients, particularly children dealing with malignant bone tumors around the knee joint. Unlike traditional amputations, this procedure aims to:

  • Preserve the patient’s foot and reattach it in a functional position
  • Rotate the lower leg 180 degrees and reattach it to the thigh bone
  • Position the foot and ankle to serve as a functional knee within a prosthetic limb

Initially used to treat infections and congenital limb deformities, the procedure has evolved dramatically. It has become a preferred method to treat bone tumors, primarily around the knee joint. The procedure is designed to maximize the functionality of the affected limb, avoiding full-leg amputation while still successfully eliminating the tumor-affected bone.

The Rotationplasty Procedure

A rotationplasty procedure, despite its complexity, holds immense promise for limb salvage. The procedure involves the removal of the affected middle section of the leg, including the shin bones, followed by the rotation and reattachment of the lower shin and foot to the thigh in a rotated orientation. This rotation allows the ankle joint to mimic the biomechanics of a natural knee. Hence the term ‘reverse foot amputation’.

The procedure typically spans six to eight hours and requires the patient to be under general anesthesia. Here are the steps involved:

  1. Segmental resection of the femur
  2. Rotation of the limb 180 degrees so the foot faces backward
  3. Reattachment of the limb The result is a functional knee joint within an artificial limb, with the ankle now acting as a knee.

Purpose and Goals

The primary reasons for reverse foot amputation are limb salvage and maintaining function. It is often a preferred choice for bone cancer patients as it allows preservation of the main nerves in the lower leg for continued function. The procedure aims to offer patients a life of mobility and independence, reducing the limitations often associated with more traditional forms of amputation.

Age and Growth Considerations

Younger patients are particularly well-suited for rotationplasty due to their continued bone growth. The procedure accommodates their growth, and the prosthetic limb can be lengthened as they mature. While there is no absolute age limit for the procedure, functional outcomes of rotationplasty tend to be better for younger patients. However, muscle adaptation has been observed in older individuals too.

Surgeons must consider a patient’s potential for growth, particularly in younger individuals, to ensure successful alignment and function following the procedure.

Bone Cancer and Tumor Removal

Reverse foot amputation presents a glimmer of hope for bone cancer patients, particularly those with the bone affected. It offers an alternative to limb-sparing surgery or full amputation that would limit engagement in high-impact activities. The procedure enables patients to achieve active control of the pseudo-knee, resulting in a gait that is near normal and more functional than the outcome typically associated with above-knee amputation.

Even for older patients with malignant bone tumors, when other limb-sparing options are not viable, rotationplasty can serve as a life-enhancing option. Patients without tumor infiltration of the sciatic nerve and with a preserved range of motion in the ipsilateral ankle are ideal candidates for reverse foot amputation.

Advantages of Reverse Foot Amputation

The goal of reverse foot amputation goes beyond merely saving a limb; it’s also about augmenting its functionality to enhance the patient’s quality of life. The procedure allows for a more active and efficient gait, leading to better limb control. It results in superior stance mechanics and the potential for more strength in the affected limb. This unique configuration of the rotated limb in rotationplasty offers intuitive prosthetic use due to the preservation of the ankle joint, which serves as a new knee, providing improved sensation, proprioception, and motor control.

Patients undergoing rotationplasty procedures often report better quality of life and higher satisfaction in daily activities and sports. Most experience no or only occasional pain. The procedure is also associated with a low complication rate and lesser post-operative pain compared to other amputation methods due in part to the avoidance of nerve cutting.

Moreover, rotationplasty is a beneficial procedure for adult patients, enhancing limb length and future ambulation capabilities.

Improved Mobility and Functionality

One of the standout benefits of rotationplasty is the improvement in mobility and functionality it offers. Patients, especially children, can maintain very active lifestyles and engage in high-impact sports such as:

  • baseball
  • soccer
  • running
  • bicycling
  • skiing
  • horseback riding

These activities would be difficult with traditional limb salvage surgery. Prosthetics designed for patients who have undergone rotationplasty closely mimic natural leg mechanics, improving gait and reducing the energy expenditure required for walking.

The procedure allows patients to achieve a more natural and efficient walking pattern as they can actively control their ankle in a rotated position, which functions as a natural knee joint. Preserving the original nerve structures gives patients better sensory feedback from the limb, enhancing balance, coordination, and the ability to perform complex movements. However, it’s worth noting that while rotationplasty improves motion and functionality, patients may encounter difficulties with complex movements such as heel walking, jumping, or navigating uneven terrain.

Prosthetic Adaptability

A significant advantage of rotationplasty is its compatibility with custom-made knee prosthesis options, such as below-knee prostheses. These offer a better fit and adaptability than traditional above-knee prosthetics, enhancing limb functionality and comfort. Post-rotationplasty, patients can achieve a satisfactory gait and bear weight on the limb, thanks to an adequate sensate stump that aligns with the level of the contralateral knee, allowing for improved prosthetic tolerance and fitting.

The prosthetics used post-rotationplasty offer several benefits, including:

  • Increased wearing time
  • Reduced fatigue
  • Improved patient well-being
  • Adaptability to engage in a wider range of high-impact activities, such as running and jumping

These benefits make rotationplasty a favorable option for patients seeking a more comfortable and active lifestyle with prosthetics.

Recovery and Rehabilitation Process

Recovering from a rotationplasty procedure involves traversing multiple stages integral to successful rehabilitation. Post-surgery, patients must wear a spica cast for approximately six weeks to facilitate bone healing, which may take three to six months. After surgery, patients usually start walking 2-4 weeks later when the prosthesis is ready and fitted to them. This enables them to gradually regain their mobility and independence.

Typically, patients undergo the following steps in their recovery after surgery:

  1. They remain in the hospital for a fortnight after the surgery to begin their recovery.
  2. They then return home and come back for prosthetist measurements after the last cast is removed, staying for approximately two more weeks.
  3. Physical therapy typically begins with 3-4 sessions per week and can last for 6-12 months before gradually moving into a home therapy program.

Hospital Stay and Initial Recovery

Immediately following rotationplasty surgery, patients are typically admitted to the intensive care unit for one or two days. The overall hospital stay usually ranges from five to six days. During this time, immediate postoperative wound care is paramount to ensure optimal healing and prevent complications.

Immediate Postoperative Wound Care in Reverse Foot Amputation

A. Surgical Site Monitoring

Vigilant Observation: Close monitoring of the surgical site for any signs of bleeding, swelling, or abnormal discharge is crucial.

Assessing Circulation: Regular checks of peripheral pulses and capillary refill to ensure adequate blood flow to the wound area.

Temperature Monitoring: Evaluating the skin temperature around the wound to identify signs of infection or impaired healing.

B. Dressing Selection and Application

Consideration of Wound Type: Selection of appropriate dressings based on the nature of the wound, such as absorbent dressings for exuding wounds or silicone-based dressings for scar management.

Maintaining Moisture Balance: Application of dressings that promote a moist wound environment while preventing excessive moisture accumulation.

Secure and Atraumatic Dressing Application: Ensuring dressings are applied securely but without causing trauma to the surrounding skin or wound area.

C. Pain Management Strategies

Pharmacological Interventions: Administration of analgesic medications prescribed by healthcare providers to alleviate postoperative pain.

Non-Pharmacological Pain Relief: Implement non-pharmacological pain management techniques such as elevation of the affected limb, application of ice packs, or relaxation techniques.

Patient Education: Providing patients with information about pain management strategies and encouraging open communication to address any concerns or discomfort.

Managing Wound Healing and Possible Complications

A. Infection Prevention and Control Measures

  • Strict adherence to aseptic techniques during dressing changes.
  • Administration of prophylactic antibiotics as per surgical protocols.
  • Regularly monitor signs of infection, such as increased redness, warmth, swelling, or purulent drainage.

B. Dealing with Delayed Healing

  • Implementing advanced wound care techniques like negative pressure wound therapy (NPWT) or bioengineered skin substitutes.
  • Optimizing nutrition and hydration to support tissue repair and regeneration.
  • Collaborating with wound care specialists for tailored treatment plans.

C. Addressing Wound Dehiscence and Necrosis

  • Prompt surgical intervention to address wound dehiscence and facilitate primary closure if feasible.
  • Debridement of necrotic tissue to promote healthy granulation tissue formation.
  • Close monitoring of wound edges for signs of further breakdown and timely intervention to prevent complications.

Two weeks after the surgery, the cast is changed to examine the surgical site following the reduction of swelling. This allows the medical team to assess the healing progress. This initial phase of recovery is crucial to ensure the successful healing and adaptation of the rotated limb.

Physical Therapy and Prosthesis Fitting

The path to recovery doesn’t end with the surgery. Prosthesis fitting and physical therapy are critical steps in regaining mobility and functionality. Successful prosthesis fitting hinges on effective communication between the patient and the prosthetist. The fitting process, which typically spans up to 6 months, may include:

  • a preliminary bypass prosthesis before the final version is introduced
  • adjustments and modifications to ensure proper fit and comfort
  • alignment and gait training to optimize walking and movement
  • regular follow-up appointments to address any issues or concerns

The design of rotationplasty facilitates easier attachment and control of the prosthesis, enhancing patient confidence and security in mobility.

Physical therapy commences soon after surgery. The initial intensive phase is often scheduled 3-4 times per week for up to 12 months, then transitioning to a home or local program regimen. Therapy includes muscle-strengthening exercises to improve prosthetic control and is personalized to align with each patient’s functional goals and lifestyle.

After the initial cast is removed, which occurs six weeks post-surgery, physical therapy focuses on a range of motion desensitization of the skin. It begins weight-bearing exercises once the prosthesis is available.

Challenges and Potential Complications

As with all surgical procedures, rotationplasty has potential complications and challenges. Possible consequences of this situation may include reduced blood supply, infections, nerve injury, and delayed healing. These factors may contribute to complications during the recovery process. Additional specific complications, though not common, can include prolonged healing of the osteotomy, implant loosening, impingement of the rotated joint, and Achilles tendon tears.

Post-operatively, while many patients successfully integrate socially, there are reports of challenges with initiating social or intimate contact and negative effects on body image. Identifying these potential challenges and effectively addressing them in collaboration with healthcare professionals is crucial.

Surgical Risks

Despite the numerous benefits of rotationplasty, acknowledging the possible surgical risks is paramount. Vascular complications can include lower-limb ischemia due to arterial or venous obstruction, reperfusion injury, and serious complications from issues with vascular anastomosis. Nerve damage is a potential risk, with transient peroneal nerve palsy being common and sciatic nerve palsy requiring immediate treatment to avoid permanent damage.

The risk for rotationplasty failure increases in patients with prior pathologic fractures and those with large tumors unresponsive to chemotherapy, potentially due to compromised blood supply or venous drainage. Other reported complications following rotationplasty include wound necrosis, tibial fractures, nonunion, and infections, though most can be managed effectively with appropriate care.

Conclusion

Rotationplasty, or reverse foot amputation, is a surgical procedure that provides an innovative solution for bone cancer patients facing limb amputation. It offers improved mobility, functionality, and the ability to engage in high-impact activities, particularly for younger patients. Despite the potential challenges and complications, with the right medical support and rehabilitation plan, patients can lead active, fulfilling lives. As the field of orthopedic surgery continues to evolve, rotationplasty is a testament to medical innovation’s power to enhance quality of life.

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