Rotationplasty

1. Rotationplasty Nathan Dugan 3 rd Year PT Student Columbia University http://www.hindawi.com/journals/sarcoma/2008/402378/fig4/

2. Objectives E xplain what rotationplasty is and how it is performed Discuss rehabilitation options for rotationplasty Discuss prosthetics relating to rotationplasty Review outcome measures that may be beneficial to administer in this population Present conclusions drawn during the course of compiling this presentation related to research and outcomes in rotationplasty

3. Background Information

4. What is Rotationplasty? Biologic reconstructive option for congenital and acquired lower extremity bone loss Indicated for: P roximal femoral focal deficiency (PFFD) S arcomas of hip, femur, proximal tibia Failed limb salvage procedures, failed THA/TKA Traumatic bone loss Severe burns with intact distal limb Gupta 2012

5. Types of Rotationplasty Type A ankle joint functions as knee joint Type B knee joint functions as hip joint, ankle joint functions as new knee joint Gupta 2012

6. Type A Rotationplasty Type AI distal femoral resection Type AII proximal tibial resection Gupta 2012

7. Type B Rotationplasty Type BI proximal femoral conditions with no hip involvement Type BII performed in the setting of hip joint or lower pelvis involvement Gupta 2012

8. Type B Rotationplasty Type BIII performed when complete resection of the femur is necessary Type BIIIa lateral condyle of the tibia is placed into the acetabulum (expected to remodel) Type BIIIb tibia is rotated and connected to pelvis with endoprosthesis Gupta 2012

9. Type B Rotationplasty Type BIIIa Type BIIIb Gupta 2012

10. Relevant Anatomy Gupta 2012

11. Rehabilitation

12. Rehabilitation Course: General Guidelines G entle PROM of the ankle and AROM/antigravity movements of hip important early-on in process Want to avoid hip flexion/adduction contractures, similar to AKA Functional training with assistive devices Progress to AROM of ankle/toes Resisted exercise typically begins 6-12 weeks post-op, when soft tissue healing is complete Advance to weight-bearing once there is evidence of healing at osteotomy site Gupta 2012, So 2014

13. Rehabilitation Course: Considerations Full weight-bearing is not allowed until osteotomy site is fully healed AROM 0-30 degrees is needed to operate knee in prosthesis (optimal PF/KE is 50 degrees ) Be mindful of pain post-operatively Gupta 2012, So 2014

14. Rehabilitation: Case Study

15. Prosthetics

16. Rehabilitation Course: Prostheses Retrospective observational study with n=12 Median age: 10 years (5-13 yrs), 8 males All patients had oncologic pathology Osteosarcoma (10), synovial sarcoma (2) So 2014

17. Rehabilitation Course: Prostheses Preliminary bypass prosthesis Allows TTWB without shearing at osteotomy site Bypasses “knee” joint No “knee” flexion through prosthesis Must use assistive device to ambulate Components: Polypropylene, ischial WB, quadrilateral sockets Total elastic auxiliary suspension Pylon and Seattle LightFoot So 2014

18. Preliminary Bypass Prosthesis So 2014

19. Rehabilitation Course: Prostheses Definitive prosthesis Acrylic laminate socket with polypropylene thigh section Anatomic suspension Calcaneal strap Removable calcaneal wedge Seattle LightFoot So 2014

20. First Definitive Prosthesis So 2014

21. How Long Did it Take? In 10 patients requiring chemotherapy 230.5 days In 2 patient not requiring chemotherapy 78.5 days Time between first and second prosthesis 18.5 months So 2014

22. Considerations for Prostheses Stops for ankle (“knee”) flex/ext Compensates for patient’s inability to control knee flexion moment at heel strike Use longest foot that can fit in shoe Provides a longer lever arm, assists in knee stability Subsequent prostheses can incorporate carbon fiber dynamic response/multiaxial foot options Allow for easy adjustments to compensate for growth So 2014

23. Innovation in Prosthetics In cycling, thigh cuff of a conventional prosthesis leads to perspiration, chaffing, and skin abrasion Case of an 18 y/o male cyclist with rotationplasty He regularly contracted abrasion injuries at foot/thigh Only able to cycle 35km (21.7mi) Scheepers 2015

24. Cycling Specific Prosthesis Design Scheepers 2015

25. Cycling Specific Prosthesis Design Scheepers 2015

26. Outcome Measures

27. Outcomes Assessment FMA (functional motor assessment), MSTS (musculoskeletal tumor society) rating scale, Toronto Extremity salvage score (TESS) SF-36v2 Gait analysis, TUG, 6MWT, ROM, MMT, etc.

28. Functional Motor Assessment (FMA) Six subcategories: Pain Function with two specific measures Timed up-and-down 12 stairs (TUDS) Timed up-and-go (TUG) Supports Satisfaction with walking quality Participation in work, school, sports Endurance 9-minute walk-run test Marchese 2007

29. Musculoskeletal Tumor Society (MSTS) Rating Scale Also known as Enneking Score Examines 6 factors Pain Functional activities Emotional acceptance Use of supports Walking ability Gait Enneking 1993

30. Toronto Extremity Salvage Score (TESS) Disease-specific measure developed for patients undergoing limb preservation surgery for tumors of the extremities Evaluates physical disability based on patients’ reports of their function 29-item lower extremity and 28-item upper extremity questionnaire Items rated on 5-point scale from “not at all difficult” to “impossible to do” Importance of each item is rated on 4-point scale from “totally unimportant” to “extremely important” Davis 1996

31. Conclusions

32. An Overall Paucity of Research Search on PubMed for “rotationplasty” yields only 154 results since 1962 Only 2.9 articles per year Overall quality of research is low Results yield many case studies/case series and few, if any, RCTs Virtually no mention of rehabilitation in the research At best, a few sentences within other studies mentioning generalities Research is concentrated in the areas of surgical techniques/complications, quality of life, and function

33. Highly Functional Individuals Individuals have been shown to be highly functional post-rotationplasty Hillman 2007, Harris 2013 Individuals often score highly on quality of life measures Forni 2012, Barrera 2012, Rödl 2002

34. https://www.youtube.com/watch?v =g28tS68dagM; http://www.rotationplasty.com/Sean-Dever

35. Q uestions?

36. References Gupta SK, Alassaf N, Harrop AR, Kiefer GN. Principles of rotationplasty. J Am Acad Orthop Surg 2012;20:657-667. So NF, Andrews KL, Anderson K, et al. Prosthetic fitting after rotationplasty of the knee. Am J Phys Med Rehabil 2014;93:328-334. Scheepers LG, Storcken JO, Rings F, et al. New socket-less prosthesis concept facilitating comfortable and abrasion-free cycling after Van Nes rotationplasty. Prosthet Orthot Int 2015;39(2):161-165. Davis AM, Wright JG, Williams JI, et al. Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res 1996;5:508-516 Marchese VG, Rai SN, Carlson CA, et al. Assessing functional mobility in survivors of lower-extremity sarcoma: reliability and validity of a new assessment tool. Pediatr Blood Cancer 2007;49:183-189. Enneking WF, Dunham W, Gebhardt MC, et al. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat R 1993;286:241-246. Hillman A, Weist R, Fromme A, et al. Sports activities and endurance capacity of bone tumor patients after rotationplasty. Arch Phys Med Rehabil 2007;88(7):885-890. Harris JD, Trinh TQ, Scharschmidt TJ, Mayerson JL. Exceptional functional recovery and return to high-impact sports after Van Nes Rotationplasty. Orthopedics 2013;36(1):126-131. Forni C, Gaudenzi N, Zoli M, et al. Living with rotationplasty – quality of life in rotationplasty patients from childhood to adulthood. J Surg Oncol 2012;105(4):331-336. Barrera M, Teall T, Barr R, et al. Health related quality of life in adolescent and young adult survivors of lower extremity bone tumors. Pediatr Blood Cancer 2012;58(2):265-273. Rödl RW, Pohlmann U, Gosheger G, et al. Rotationplasty – quality of life after 10 years in 22 patients. Acta Orthop Scand 2002;73(1):85-88.