Rehabilitation guidelines following Distal Femoral Diaphyseal
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
sensitive to chemotherapy/radiotherapy). These treatments will impact on
their rehabilitation. (Refer to the Appendix for further details)
Distal Femoral Diaphyseal Replacement
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Distal Femoral Diaphyseal Replacement
Therapy Rehabilitation
Excision of femoral diaphysis and insertion of diaphyseal
replacement
Indications:
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Bone tumour of the distal femur with no involvement of the adjacent
joints
Possible complications:
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Wound healing/infection
Neuropraxia
Aseptic loosening
Recurrence
Poor ROM requiring MUA
Expected outcome:
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May take 6-9 months to achieve optimal function
ROM at knee 0 - 120
Independently mobile with no aids
Main muscles affected:
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Gastrocnemius, quadriceps, hamstrings
Initial rehabilitation phase
0 to 6 weeks
Goals:
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Optimise tissue healing
Ensure adequate pain control
Patient to be independently mobile
Ensure knee ROM 0-90
Ensure grade 3 quadriceps
Restrictions:
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Weight bearing may be restricted
Range of movement may be restricted, dependent on the extent of
surgery undertaken
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Orthotic appliances:
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Patient may be required to wear a cast brace/knee brace if there are
concerns about knee stability
Pain relief:
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Adequate analgesia, resting positions
Patient education:
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Post operative restrictions, rehabilitation guidelines
Physiotherapy rehabilitation:
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Static muscle strengthening and circulatory exercises
Patient is taught active knee flexion/extension. Aiming to achieve knee
ROM 0 - 90, if appropriate
Commence active quadriceps/hamstring strengthening exercises
Mobilise with appropriate walking aid. Weight bearing status will be
determined by fixation of prosthesis and also proximity to the joint
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 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 to 12 weeks
Goals:
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Improve lower limb function focussing on muscle imbalance around
knee
Regain strength in quadriceps
Maintain / increase knee range of movement
Wean from walking aids
Pain relief:
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Adequate analgesia
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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
Work on balance
Ensure even weight bearing through lower limbs (if appropriate)
Improve proprioception throughout lower limb
Core stability work
Encourage self management and independence with exercise
programme
Hydrotherapy may be beneficial at this stage
Final rehabilitation phase
12 weeks and beyond
Goals:
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Return to function including full ADL, work, school etc
Patient education:
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Encourage return to normal function
Physiotherapy rehabilitation
As per 6-12 weeks especially working on:
 Gait re-education
 Proprioception work
 Ensure patient is independent with own management and has achieved
maximum functional independence
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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 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
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