Rehabilitation guidelines following Tibial Diaphyseal Replacement

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)

Tibial Diaphyseal Replacement

Therapy rehabilitation guidelines

Tibial Diaphyseal Replacement

Excision of tibial diaphysis and insertion of diaphyseal replacement.

Indications:

  • Bone tumour of the tibia with no involvement of adjacent joints.

Possible complications:

  • Wound healing/infection
  • Neuropraxia
  • Aseptic loosening
  • Recurrence
  • Poor ROM requiring MUA

Expected outcome:

  • May take 6-9 months to achieve optimal function
  • Full ROM at knee
  • 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
  • Ensure knee ROM 0-90

Restrictions:

  • Weight bearing may be restricted – see post operative instructions
  • May not be allowed to use quadriceps if they have been detached

Orthotic appliances:

  • Routinely not indicated, however, patient may be required to wear a cast brace or knee extension splint/hinge brace if there are concerns about knee stability or if no active quadriceps function

Pain relief:

  • Adequate analgesia
  • Resting positions

Patient education:

  • Post operative restrictions
  • Rehabilitation guidelines

Physiotherapy rehabilitation

  • Static muscle strengthening and circulatory exercises commence from day 1
  • Patient is taught active knee flexion/extension, aiming to achieve knee ROM 0 - 90
  • Patient is taught active dorsi/plantar flexion ensuring plantargrade achieved.
  • Commence quads strengthening exercises if appropriate
  • Mobilise with appropriate walking aid
  • Practice stairs as appropriate
  • Encourage self management and independence with exercises, prior to hospital discharge.
  • 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 also 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 focussing on muscle imbalance around knee.
  • Regain strength in quadriceps
  • Maintain knee range of movement
  • Wean from walking aids

Pain relief:

  • Adequate analgesia

Physiotherapy rehabilitation

  • Active quadriceps strengthening through range – closed and open chain
  • Ensure even muscle balance and activation around knee
  • Continue to work on knee ROM
  • Teach scar massage techniques
  • Gait re-education
  • Wean walking aid as appropriate
  • Work on balance - single and dual leg
  • Ensure even weight bearing through lower limbs
  • Improve proprioception throughout lower limb
  • Hydrotherapy may be beneficial at this stage
  • Core stability work
  • Encourage self management and independence with exercise programme

Final rehabilitation phase

12 weeks onwards

Goals:

  • Return to function

Patient education

  • Encourage return to normal function.

Physiotherapy rehabilitation:

  • Gait re-education
  • Proprioception work
  • Ensure patient is independent with own management

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

In association with the UCL Institute of Orthopaedics and Musculoskeletal Science