Rehabilitation guidelines following Excision of Ilium with
Fibula Strut Graft
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)
Excision of Ilium with Fibula Strut Graft
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Therapy rehabilitation
Excision of Ilium with Fibula Strut Graft
A portion of the ilium is excised and replaced with one or two struts of bone
taken from the fibula.
Indications:
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Bone tumour of ilium
Possible complications:
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Wound healing/infection
Neuropraxia
Recurrence
Increased soft tissue sacrificed due to tumour site
Displacement of fibula strut
Fracture of fibula strut
Oedema / Haematoma
DVT
Expected outcome:
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May take 12 – 18 months to achieve optimal function even if input
towards the end is periodic
Independently mobile with no mobility aids or a stick
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
Contact and impact sports should be avoided
The patient will be independent in relevant personal care and domestic
activities (with or without adaptive equipment) or provision made for
assistance with this on discharge.
Activities such as swimming and cycling are possible
Muscles affected:
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Iliopsoas, quadratus lumborum, abdominals and origin of glutei (these
are the main muscles involved. However may alter according to the
tumour location and amount of soft tissue involved)
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Initial rehabilitation phase
0 to 12 weeks
Goals:
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Improve hip ROM, strength and stability within restrictions
Patient to be independently mobile with appropriate walking aid
Optimise tissue healing
Ensure adequate pain control
In instances where independence is not achieved, ensure there is
adequate support in place to optimise safety in the home during the
post-operative period.
Restrictions:
 No hip flexion above 90
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No hip adduction beyond midline
No abduction against gravity
No internal rotation of operated hip beyond midline
No twisting on operated hip
Weight bearing may be restricted. See individual post-operative
instructions.
Orthotic appliances:
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No orthotic appliances required routinely.
Pain relief:
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Adequate analgesia, resting positions
Patient education:
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Post operative restrictions
Rehabilitation guidelines
Education regarding functional activities
Initial rehabilitation phase
0-12 Weeks
Physiotherapy Intervention
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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 2-5 days 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
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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
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
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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 lenth + 2” / 5cm)
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 once home.
Intermediate rehabilitation phase
12 weeks to 6 months
Goals:
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Increase strength and ROM of LL concentrating particularly on the hip
and knee
Improve pelvic/core stability
Improve gait pattern/progress walking aids
Patient education:
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Advice regarding pacing in activities
Advice regarding return to functional activities
Physiotherapy rehabilitation:
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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 they have adequate hip control
May start sleeping on operated side from 3 months post op
Once hip control is sufficient, they may recommence swimming. ( may
need to adapt the strokes used)
Occupational Therapy rehabilitation
(seen if referred and appropriate for rehabilitation at this stage.)
 Re-assess personal care management, transfers and domestic ADLs.
 Discussion re: work including ergonomics if relevant
 Pacing / Energy conservation techniques
 Safer handling techniques, taking into consideration the walking aids
the patient has progressed onto.
 Address any relationship/intimacy issues
Late rehabilitation phase
6 months to 1 year
Goals:
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Return to optimal function, encouraging restoration of previous work
and leisure activities (avoiding contact sports and impact activities).
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Patient education:
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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:
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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
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To review if required and work upon any difficulties the patient may still
be experiencing including return to work, leisure, relationships /
intimacy.
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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
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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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