Rehabilitation guidelines following Proximal Tibial

Replacement Surgery

Much of the surgery carried out on the Sarcoma Unit at RNOHT is unusual. We have therefore devised guidelines which outline the goals patients should be aiming to achieve during their rehabilitation. These are guidelines and every patient should be assessed and treated as an individual, therefore, there may be variation in timing and outcome but the restrictions MUST remain the same.

Patients who have been diagnosed with a tumour and then undergone orthopaedic surgery are, if appropriate, referred for pre/post op chemotherapy or radiotherapy. (Not all tumours are malignant and not all tumours are chemotherapy/radiotherapy sensitive). These treatments will impact on their rehabilitation.

(Refer to the Appendix for details)

Proximal tibial replacement

Therapy Rehabilitation

Proximal Tibial Replacement

Proximal third of the tibia is removed and replaced by a custom built hinged knee replacement. The patella tendon is either attached at the original level of the tibial tuberosity to the prosthesis with a small amount of bone graft and clamped with a plate and screw or sutured to soft tissues. A flap is created from gastrocnemius and brought anteriorly to reinforce the patella tendon attachment.

Indications:

·  Bone tumour of the proximal tibia

Possible complications:

·  Wound healing/infection

·  Neuropraxia

·  Aseptic loosening

·  Recurrence

·  Poor patella tracking/patella dislocation

·  Poor ROM requiring MUA

·  Patella tendon detachment

·  Patella tendon stretching resulting in a quadriceps lag.

Expected outcome:

·  May take up to a year to achieve optimal function

·  ROM at knee 0 - 120°

·  10°-20° quads lag

·  Independently mobile with no aids

Muscles affected:

·  Gastrocnemius, quadriceps, hamstrings

Initial rehabilitation phase

0 – 6 weeks

Goals:

·  Optimise tissue healing

·  Ensure adequate pain control

·  Patient to be independently mobile

·  Patient is taught passive knee flexion with passive extension. Aiming to achieve knee ROM 0 - 90° although range should not be pushed beyond comfort. Some patients may have a restricted range for the first weeks post-operatively to ensure that fixation of the quadriceps is not put under detrimental tension.

Restrictions:

·  No active knee flexion or extension for 6 weeks

Orthotic appliances:

·  Knee extension brace (either cricket pad splint or hinge knee brace locked in extension) to be worn whenever patient is out of bed

Pain relief:

·  Adequate analgesia, resting positions

Patient education:

·  Post operative restrictions, rehabilitation guidelines, how to donn and doff brace

Physiotherapy rehabilitation:

·  Static muscle strengthening and circulatory exercises commence from day 1. Aim for full dorsiflexion, this is especially important because of the gastrocnemius flap

·  Patient is taught passive knee flexion with passive extension. Aiming to achieve knee ROM 0-90 but monitor closely for excessive wound ooze and range should be within comfort. Some patients may only be allowed to flex/extend their knee with supervision.

·  Mobilise with appropriate walking aid wearing a knee extension brace

·  Practice stairs as appropriate

·  Prior to hospital discharge patients must be referred for outpatient physiotherapy. If patients are also going to receive chemotherapy or radiotherapy then a transfer summary must be sent to the centre that will be carrying out adjunctive therapy

Occupational Therapy Intervention

Occupational Therapy is not routinely indicated, however, other members of the MDT may make referrals for any specific OT related problems that the patient may be experiencing.

Intermediate treatment phase

6 – 12 weeks

Goals:

·  Improve lower limb function – focus on muscle balance around the knee

·  Regain strength in quadriceps / hamstrings

·  Wean from brace

·  Increase knee range of movement

·  Wean from walking aids

Orthotic appliances:

·  Start to wean as quads control improves

Pain relief:

·  Adequate analgesia

Physiotherapy rehabilitation:

·  Commence active quadriceps strengthening – closed and open chain

·  Commence active knee ROM

·  Gait re-education

·  Ensure even weight bearing through lower limbs

·  Wean walking aid as appropriate

·  Balance – single and dual leg

·  Proprioception throughout lower limb

·  Hydrotherapy may be beneficial at this stage

·  Core stability work – focus particularly on gluts and VMO

·  Once quads control is adequate patients may recommence driving

Final rehabilitation phase

12 weeks onwards

Goals:

·  Return to function

Orthotic appliances:

·  Quadriceps control should be sufficient to no longer require external support

Patient education

·  Encourage return to optimal function.

Physiotherapy rehabilitation

Continue rehab to achieve optimal functional outcome according to patients needs including:

·  Gait re-education

·  Proprioception work

Appendix

Some chemotherapy and radiotherapy side effects and implications for treatment:

·  Bone marrow toxicity, ↓white cell count, ↓platelets, ↓Hb and ↓rate of healing. White cell count will be at its lowest approximately 10 days post chemotherapy and signs of wound infection should be watched for. Hydrotherapy should not be undertaken at this point

·  Nausea, vomiting, diahorrea, ↓appetite, lethargy and ↓exercise tolerance. Physiotherapy will be particularly important during and immediately after chemo and radiotherapy, as patients often lose ROM and strength after a cycle. Community physiotherapy may need to be arranged after discharge if the patient is too unwell to attend for outpatient treatment. The occupational therapist may need to advise on the practical implications of the symptoms such as meal and drink preparation, laundry and hygiene. Relaxation techniques may also be used to reduce nausea and vomiting in addition to reducing anxiety levels associated with food and meal times.

·  Anxiety and depression – these can diminish people’s concentration, ability to assimilate information and motivation to carry out activities. The therapists, among other treatment, will identify goals which increase a person’s sense of control.

·  Fatigue – needs to be addressed / acknowledged as it can affect a person’s physical and cognitive ability to carry out normal activities. The therapists will need to take this into consideration and tailor the rehabilitation accordingly.

·  Anaemia which can lead to tiredness, lethargy and breathlessness)

Radiotherapy only:

·  Fibrosis of soft tissues – Can continue for up to 2 years and may lead to contractures. Passive exercise is very important during and immediately post radiotherapy to prevent loss of ROM.

·  Demineralisation of bone – increases risk of fracture

·  Redness, soreness and sensitivity of the skin to heat - care of the skin is important . Heat modalities are contraindicated post DXT. Application of lotions and manual treatments are contraindicated during DXT, but can be used with caution post DXT. Electrical modalities e.g.TNS and FES can be used with caution.

RC/SH/KS March 2014 Review date: March 2016