Rehabilitation guidelines following Distal Femoral
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).
Distal Femoral Replacement
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Therapy Rehabilitation
Distal Femoral Replacement
Distal portion of the femur (up to two thirds is excised) and replaced by a
endoprosthesis incorporating a hinged total knee replacement.
Indications:
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Bone tumour of the distal femur
Possible complications:
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Wound healing/infection
Neuropraxia
Aseptic loosening
Recurrence
Poor patella tracking/patella dislocation
Poor ROM requiring MUA
Poor muscle control/power esp if extensive soft tissue excision
Expected outcome:
 May take 6-9 months to achieve optimal function

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ROM at knee 0 - 120
Independently mobile with no aids
Main muscles affected:

Gastrocnemius, quadriceps, hamstrings
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Initial rehabilitation phase
0-6 weeks
Goals:
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Optimise tissue healing
Ensure adequate pain control
Patient to be independently mobile with aid(s)
Ensure knee ROM 0-90
Ensure grade 3 quadriceps
Restrictions:
 No restrictions
Orthotic appliances:
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None
Pain relief:
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Adequate analgesia, resting positions, ice
Patient education:
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Rehabilitation guidelines, home exercise programme
Physiotherapy rehabilitation:
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Static muscle strengthening and circulatory exercises
Patient taught active/active assisted knee flexion/extension as soon as
possible. Aiming to achieve knee ROM 0 - 90
Commence quadriceps/hamstring strengthening exercises as soon as
possible
Mobilise with appropriate walking aid
Practice stairs as appropriate
Encourage self management and independence with exercise
programme
Hydrotherapy at this stage may be appropriate only if wound and
immune status allows
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.
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Intermediate treatment phase 6-12 weeks
Goals:
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Improve lower limb function focussing on muscle imbalance around
knee and core stability.
Regain strength in quadriceps/hamstrings
Maintain/improve knee range of movement
Wean from walking aids
Pain relief:

Adequate analgesia
Physiotherapy rehabilitation:
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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 if appropriate
Gait re-education
Wean walking aid as appropriate
Balance work
Ensure even weight bearing
Improve proprioception throughout lower limb
Hydrotherapy may be beneficial at this stage
Core stability work
Encourage self management and independence with exercise
programme
Late rehabilitation phase
12 weeks and beyond
Goals:

Return to function including full ADL, work, school etc
Patient education:

Encourage return to normal function
Physiotherapy rehabilitation
As per 6-12 weeks especially working on:
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Gait re-education
Proprioception work
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Ensure patient is independent with own management and has
achieved maximum functional independence
Appendix
Some chemotherapy and radiotherapy side effects and
implications for treatment:
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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
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Fibrosis of soft tissues – can continue for up to two 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
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