Rehabilitation guidelines followingHemipelvic

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 further details).

Hemipelvic replacement

RC/SH/KS March 2014 Review March 2016

Therapy rehabilitation

Hemipelvic replacement

The affected section of the hemipelvis is excised and replaced with an endoprosthetic replacement incorporating an acetabular component which is secured into the remaining ilium and a standard total hip replacement component, forming a hip joint.

Indications:

  • Bone tumour of the hemipelvis

Possible complications:

  • Wound healing/infection
  • Dislocation – often due to poor muscular control
  • Neuropraxia
  • Aseptic loosening
  • Recurrence
  • Hip contractures

Expected outcome:

  • May take 12 – 18 months to achieve optimal function even if input towards the end is periodic
  • Independently mobile with one stick (optimal)
  • Independent with relevant personal care and domestic activities (with or without equipment) or provision made for assistance with this on discharge.
  • Contact sports and impact activities should be avoided due to prosthetic loosening
  • Activities such as swimming and cycling are possible
  • Grade 4 hip abduction is an optimal outcome, some patients may not achieve this and will then walk with a trendelenburg gait or lateral tilt bend

Muscles affected:

  • Iliopsoas, origin of glutei, hip rotators, hip abductors, hip extensors

Initial rehabilitation phase

0 to 12 weeks

Goals:

  • Improve hip ROM, strength and stability within restrictions
  • Patient to be independently mobile with appropriate walking aid
  • Optimise tissue healing
  • Ensure adequate pain control
  • To be independent in relevant personal care activities, with or without adaptive equipment or provision made for assistance with this on discharge.
  • To be independent and safe in all relevant functional transfers (with or without adaptive equipment) or provision made for assistance on discharge.

Post-operative Precautions / Restrictions:

  • No hip flexion above 90
  • No hip adduction beyond midline
  • No abduction against gravity
  • No internal rotation of operated hip beyond midline
  • No twisting on operated hip

Orthotic appliances:

  • Patients may be required to wear an abduction brace if they have insufficient hip control or if deemed necessary at time of surgery e.g. if a small femoral head is used. The brace is to be worn anytime the patient is out of bed (don and doff on the bed)

Pain relief:

  • Adequate analgesia, resting positions

Patient education:

  • Post operative restrictions
  • Rehabilitation guidelines
  • Education regarding functional activities
  • Don and doff brace

Physiotherapy rehabilitation:

  • From day 1 patient’s leg is positioned in neutral rotation supported in a trough with additional support if required. Static muscle work commences
  • From approximately 2-5days post op, slings and springs are set up over the patient’s bed.Patients are taught ankle dorsi/plantaflexion, active hip flexion, hip abduction, hip extension and knee extension exercises. Patients remain on slings and springs until grade 2 abduction is achieved
  • Once grade 2 hip abduction has been achieved patient commences sliding board exercises focusing on hip flexion and hip abduction with good control
  • Maintain full AROM at knee and ankle
  • Once grade 2 abduction is achieved the patient may mobilise wearing anabduction brace if required.
  • Teach to don and doff brace independently
  • Gait re-education with appropriate walking aid adhering to weight bearing restrictions
  • Practice stairs as appropriate
  • Encourage self management and independence with exercise programme
  • Outpatient physiotherapy will be organised locally on discharge. If the patient is having chemotherapy or radiotherapy transfer information also needs to be sent to the physiotherapist at that centre

Occupational Therapy intervention:

  • Once grade 2 abduction is achieved, carry out bed, chair, toilet, bath, car transfers as appropriate, maintaining the post-operative precautions.
  • Carry out personal care assessment using relevant adaptive equipment. Include donning/doffing of the abduction brace to reinforce practice already carried out.
  • Carry out domestic ADL assessment as appropriate.
  • Give recommended sitting height = popliteal leg length plus 2” / 5 cm.
  • Heights of furniture are requested and advice given on any necessary adaptations required.
  • Provision of equipment from the hospital and/or follow up to confirm Social Services equipment is in situ.
  • Address driving, work and leisure priorities for the patient and advise re: safe tasks for this stage of the rehabilitation phase.
  • Provide advice on and education about relaxation techniques.
  • To teach fatigue and energy conservation techniques if appropriate.
  • Address any other important and realistic patient goals at this stage.
  • If indicated, refer to Social services for anticipated equipment or care package needs for discharge.
  • If indicated, refer to relevant community teams for anticipated follow up and rehabilitation needs prior to discharge home or within the home.

Intermediate rehabilitation phase

12 weeks to 6 months

Goals:

  • Increase strength and ROM of LL concentrating particularly on the hip, knee.
  • Improve pelvic/core stability
  • Improve gait pattern/progress walking aids
  • Wean out of the brace

Patient education:

  • Advice regarding weaning from the brace
  • Advice regarding pacing in activities
  • Advice regarding return to functional activities

Physiotherapy rehabilitation:

  • Commence ROM and strengthening work against gravity (grade 3 >) only once good ROM and strength have been gained with gravity eliminated
  • Hydrotherapy may be beneficial at this stage
  • Gait re-education
  • Progress walking aid
  • Work to improve core stability and posture – focus particularly on gluts in NWB and WB positions
  • Lower limb proprioception
  • Improve weight transference
  • Improve balance – dual leg to start
  • Encourage self management and independence with exercise programme
  • May resume driving once brace is removed and they have adequate hip control

Occupational Therapy rehabilitation

  • To review if required and work upon any difficulties the patient may still be experiencingincluding return to work, leisure, relationships / intimacy.

Late rehabilitation phase

6 months to 1year

Goals:

  • Return to optimal function, encouraging restoration of previous work and leisure activities (avoiding contact sports and impact activities).

Patient education:

  • Encourage return to normal function; advise that there may continue to be an improvement in function for up to 18 months post op

Physiotherapy rehabilitation:

  • Core stability – especially in dynamic positions
  • Wean from mobility aids as appropriate
  • Encourage to attend local pool if hydro successful
  • Posture correction
  • Gait re education
  • Encourage self management and independence with exercise

programme

Occupational Therapy rehabilitation

  • To review if required and work upon any difficulties the patient may still be experiencing including return to work, leisure, relationships / intimacy.

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, diarrhoea, ↓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 March 2016