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
RC/SH/KS March 2014
Review March 2016
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:
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Bone tumour of the proximal tibia
Possible complications:
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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:
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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:
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Gastrocnemius, quadriceps, hamstrings
RC/SH/KS March 2014
Review date: March 2016
Initial rehabilitation phase
0 – 6 weeks
Goals:
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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:
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No active knee flexion or extension for 6 weeks
Orthotic appliances:
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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:
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Adequate analgesia, resting positions
Patient education:
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Post operative restrictions, rehabilitation guidelines, how to donn and doff brace
Physiotherapy rehabilitation:
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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 .
RC/SH/KS March 2014
Review date: March 2016
Intermediate treatment phase
6 – 12 weeks
Goals:
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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:
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Start to wean as quads control improves
Pain relief:
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Adequate analgesia
Physiotherapy rehabilitation:
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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:
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Return to function
Orthotic appliances:
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Quadriceps control should be sufficient to no longer require external support
Patient education
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Encourage return to optimal function.
Physiotherapy rehabilitation
Continue rehab to achieve optimal functional outcome according to patients needs
including:
 Gait re-education
 Proprioception work
RC/SH/KS March 2014
Review date: March 2016
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, 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:
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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.
RC/SH/KS March 2014
Review date: March 2016