A CHANCE AT CHILD’S PLAY: Mobility offered by surgery using amputated ankle as knee joint

Isaac Escobedo has a prosthetic leg. But you wouldn't know unless you lifted his right pant leg, revealing the red flame design on the artificial limb.

The first-grader walks, jumps, squats and sits like your average 6-year-old.

But where Isaac, a cancer survivor, differs from other amputees is his prosthesis doesn't attach in the upper thigh area, which typically requires an uncomfortable belt around the waist and causes a noticeable limp.

Isaac's prosthesis stops where his knee once was located, the result of a rare procedure known as rotationplasty.

Rotationplasty was introduced in the 1950s in Canada. It was primarily used for children with congenital limb differences but also is an option for children and adults with cancerous tumors of the femur or tibia, as in Isaac's case.

The procedure, performed by Las Vegas pediatric orthopedic surgeon Mark Barry, resulted in Isaac's leg being amputated above the knee. Barry then removed the tumor from Isaac's lower leg area. Then he rotated Isaac's lower leg 180 degrees and reattached it to the upper leg so the ankle became the knee joint. Isaac's nerves and arteries remained intact.

Having the ankle joint in the position the knee once was creates a functional and natural knee with the toes providing sensory feedback to the brain.

"The foot is now the lever that powers the artificial leg,'' said Barry, who performed the procedure on Isaac at Sunrise Children's Hospital in March 2007. "The function is much better than if you would have had the above-knee amputation. You would have to mount the artificial leg to a shorter stump."

Barry said people who have traditional above-knee amputations walk with a more visible limp as they put pressure on the artificial leg. And they are unable to participate in certain sports, either with or without the artificial leg.

With rotationplasty, children can run, jump on a trampoline and engage in sports, including swimming, Barry said. "These kids are very functional, which is essential to young children. The other important point is that these kids do not get ... phantom pains because we do not cut the nerves.''

According to the Merck Manual of Medical Information, phantom limb pain is felt in an area that has since been amputated. The brain misinterprets the nerve signals as coming from the amputated limb. The pain, caused by a change in the nervous system, may resemble squeezing, burning, or crushing sensations.

"This is very bothersome and, sometimes for children and adults, debilitating,'' Barry said. "They may need to take antidepressant drugs for the pain."

Isaac, who likes computer games more than outdoor sports, does play soccer, he said.

His father, Vincente Flores-Escobedo, said it wasn't a difficult decision to have rotationplasty. Once Barry told him that Isaac would be able to function better, Flores-Escobedo said the decision came easy.

"He walks fine. He's perfect. There's nothing he can't do.''

Hector and Maria Soto, whose 5-year-old son Enrique had the procedure about two weeks ago, hope for an outcome similar to Isaac's.

Enrique was diagnosed with cancer of the leg in December. The tumor was removed after a few rounds of chemotherapy to reduce its size, Hector Soto said. In order to prepare Enrique's family for the procedure, Barry and Dr. Jonathan Bernstein asked Isaac's family to meet with them.

Bernstein is a Las Vegas pediatric hematology-oncology physician who is currently treating Enrique and who also treated Isaac.

"I'm a mechanic and when something's wrong, I like to have options,'' Hector Soto said. "I was told, 'Either we cut the leg or he's going to die.' So we cut the leg. ... We talked to them (Isaac's parents) and they told us what to expect."

Enrique, who gets around in a wheelchair, will be fitted for a prosthesis in about a month.

His foot, which has replaced his knee, rests on a pillow in the wheelchair.

Though he's not very talkative, his parents said he loves to sing. But that has tapered off since the surgery.

Rotationplasty is not a common procedure in the United States, said Barry, who has performed the procedure only 15 times in his career.

He learned the procedure at the Hospital for Sick Children in Toronto.

The appearance of the limb after rotationplasty is very unusual and is a concern for many people from a cosmetic and psychological standpoint. Barry said explaining it to parents takes time.

"It is very difficult,'' Barry said. "We are fortunate to have had a child (Isaac) that's a year out that's functioning so well to use as an example. Otherwise, I have pictures and videos. But that's nothing like showing a child functioning so well.''

Even still, Hector Soto said Barry could have shown up with flowers to describe the procedure, and it wouldn't have lessened the pain of knowing his son was having a leg amputated.

"There's no easy way to say it,'' Soto said, leaning against a counter inside the playroom at Sunrise Children's Hospital. "I can tell you, like a father, when they tell you they are going to cut the leg off your kid, it hurts. It didn't matter what procedure (Enrique had); they're cutting off your kid's leg."

Barry said rotationplasty works well in young children because they are determined, they want to be active and they want to be healthy. Additionally, young children are still growing, he said.

Eventually, Barry said, Enrique's right leg will catch up to his left leg so that the "knees" are equal.

Contact reporter Annette Wells at awells @reviewjournal.com or 702-383-0283.