Rehabilitation after total femur replacement: a report of 2 cases1
Pesi Katrak, MB BS, FRCP, FAFRM
,
,
Abstract
We describe the rehabilitation of 2 patients who underwent total femur replacement after neoplastic involvement of the bone. In the past, patients with cancer of the femur were generally advised to undergo a hip disarticulation or transfemoral amputation. It is now feasible to salvage the limb in selected patients, by excising the entire femur together with any contiguous soft tissue tumor and replacing it with an endoprosthesis. The surgical literature contains a number of reports on total femur replacement, which mention the rehabilitation aspects only briefly, but we found nothing on this relatively uncommon form of surgery in the rehabilitation literature. Physiotherapy techniques such as active assisted exercises, isometric exercises, and hydrotherapy are extremely useful during the early phase of rehabilitation to facilitate a graduated strengthening program. Certain exercises, such as active hip abduction or knee flexion, may not be permitted for several weeks to protect muscles that have been reattached to the prosthesis. Partial weight bearing may be required to allow incorporation of bone allograft around the prosthetic hip joint. Because of these factors patients with total femur replacement may need a longer period of rehabilitation (6–8wk) than patients with total hip or knee replacement. Patients with total femur replacement can, however, achieve full independence with an appropriate rehabilitation program.
LIMB SALVAGE SURGERY with en-bloc excision of tumor and replacement with some form of endoprosthesis has become an accepted method of treatment for selected patients with cancer of the femur in the last decade.1 In the past, the usual surgical treatment offered for extensive involvement of the femur by primary or secondary tumor was a hip disarticulation or above-the-knee amputation. With the advent of diagnostic techniques such as computed tomography (CT) scan, magnetic resonance imaging (MRI), and bone scan it is now possible to define more precisely the extent of bone and soft tissue involvement. This, together with the introduction of adjuvant chemotherapy and newer surgical techniques, has allowed for limb salvage surgery rather than amputation in selected patients and has improved the prognostic outlook and functional outcome of these patients.
The surgical literature contains a number of reports on results of endoprosthetic replacement of the distal femur or the proximal femur and a few reports on total femur replacements.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 These articles emphasize the surgical issues and the outcome related to survival, but mention the rehabilitation aspects only briefly. Moreover, we could find no publications on this relatively uncommon form of surgery in the rehabilitation literature. Broad principles of rehabilitation after total hip and total knee arthroplasty are applicable in patients after total femur replacement. However, these patients present some special challenges, because the surgery involves not only the replacement of the hip and knee joints but also the excision of large portions of several muscles and reattachment of these muscles. Patients with these massive implants and muscle transfers generally require protected weight bearing and modification to the strengthening program. Our report describes details of the rehabilitation process in 2 patients after total femur replacement.
Case descriptions
Case 1
This 70-year-old retired farmer was diagnosed to have a grade I chondrosarcoma of the left femur in August 1998. Radiography showed a lytic lesion in the proximal femur extending to midshaft. CT and MRI scans showed a large 6- to 7-cm, partly calcified, soft tissue mass adjacent to the femoral head and neck with cortical and medullary destruction and invasion of the gluteus medius and piriformis muscles. There were no metastatic lesions. In June 1999, he underwent en-bloc resection of the tumor together with excision of the entire femur, extra-articular acetabular resection, and replacement of the femur, hip, and knee joints using a Kotz modular prosthesis.a Meticulous dissection was performed to ensure that a rim of uninvolved soft tissue was preserved around the entire excised specimen. Joint stabilization was achieved with hip abductor reconstruction using the residual gluteus maximus muscle and an acetabular bone allograft to reconstitute the defect after the extra-articular resection.
Immediate postoperative care included Hamilton-Russell traction for 5 days, thromboprophylaxis with subcutaneous dalteparin sodium (40mg daily), compression stockings, and sequential calf compression. Antibiotic cover with oral cephalexin was provided for 3 months. On postoperative day 3, the patient was helped to sit on the side of the bed and began quadriceps exercises; on day 4 he was assisted to stand in a forearm support frame with touch weight bearing on the left foot. A routine Doppler study 1 week after surgery revealed left femoral vein thrombosis despite the above measures for prevention of deep venous thrombosis (DVT). DVT was managed with therapeutic doses of subcutaneous dalteparin sodium (100mg daily for 6wk), and a Doppler study 1 week later already showed clot resolution. His rehabilitation was not delayed by this DVT.
He was transferred to the rehabilitation unit 2 weeks after surgery. The orthopedic surgeon had advised “no active straight leg raising or active hip abduction for 6 weeks and touch weight bearing for 12 weeks postoperation to allow the allograft to become well incorporated.” Examination of muscle strength at that stage showed grade 2 strength on the Medical Research Council Scale (0, complete paralysis; 5, normal strength) in the left quadriceps, glutei, and hamstring muscles. The left hip and knee had 35° and 65° of passive flexion, respectively. Active range of motion (ROM) of the left knee was 40° of flexion. A major functional problem was difficulty sitting because of reduced trunk and hip flexion due to pain and restriction of joint movement. A modified wedge cushion on a high chair proved to be very effective. Transfers on and off bed and chair required the assistance of 1 person. He was able to walk a few meters using a forearm support frame with touch weight bearing on the left leg.
The patient began a gymnasium and hydrotherapy program starting with 30 minutes on each activity daily, increasing over a 4-week period to 90 minutes on each activity each day. His gym program included the following exercises, starting with low numbers of repetitions (eg, 3 sets of 5 repetitions) and increasing as muscle strength allowed: isometric gluteus, quadriceps, and hamstring exercises while supine; quadriceps and hamstring cocontractions with the knee at 0° and 30° of flexion; passive knee and hip ROM exercises while supine; active assisted knee flexion while supine; passive hip adductor stretches while supine; sitting trunk flexion progressing to sit-to-stand practice encouraging forward flexion of the trunk; and manual calf stretches while supine and quads stretches while sitting.
Within 2 weeks the patient developed better knee and hip control and progressed to active knee flexion while sitting with support under the femur, standing hamstring exercises with assistance, and mini squats while touch weight bearing. Gait education involved progressing from forearm support frame to axillary crutches within 14 days on the rehabilitation program and then on to independence with elbow crutches. Outdoor mobility and stairs practice were also included in the physiotherapy program.
A hydrotherapy program was undertaken daily using the deep end of the pool and a hoist to transfer in and out. The exercises in the water included walking forward and backward initially and then sideways when active abduction was permitted at 6 weeks postsurgery. Other pool exercises included mini squats, hip and knee flexion, and hip extension exercises. The patient was able to progress from 10 repetitions of each exercise to 30 and 40 repetitions within a 2- to 3-week period.
With occupational therapy he achieved independence in activities of daily living and car transfers. He continued as an inpatient on the rehabilitation ward for a relatively long period (2mo), partly because he required radiotherapy over a 4-week period. During this time he continued on a modified program of daily physiotherapy and hydrotherapy due to fatigue associated with treatment. At discharge from hospital, he was mobilizing independently on elbow crutches with touch weight bearing, had active left knee flexion of 80°, hip flexion (while supine with knee flexed) of 60°, and trunk flexion while sitting of 70°. He did not receive further rehabilitation as an outpatient because he lived a long distance away from the rehabilitation unit.
At the most recent review nearly 2
years after total femur replacement, he was pain-free in the left leg, having previously complained during the first year of minor shin ache presumed secondary to a mismatch of the modulus of elasticity between the stiff implant in the tibia and the more flexible bone. There has been no evidence of recurrent tumor clinically or radiologically. One crutch in the right hand is still used to aid mobility, but he can walk more than 2km at a time. Hip ROM is almost full and knee flexion is 85°.
years after total femur replacement, he was pain-free in the left leg, having previously complained during the first year of minor shin ache presumed secondary to a mismatch of the modulus of elasticity between the stiff implant in the tibia and the more flexible bone. There has been no evidence of recurrent tumor clinically or radiologically. One crutch in the right hand is still used to aid mobility, but he can walk more than 2km at a time. Hip ROM is almost full and knee flexion is 85°.Case 2
A 53-year-old woman developed metastatic disease 7 years after a mastectomy for breast cancer. A bone scan showed multiple hot spots in several bones including the left tibial plateau and left femur extending throughout the femoral shaft and distal femur. Pathologic fractures were seen in the left lateral femoral condyle and left tibial plateau on radiographs (fig 1). CT and MRI scans confirmed these findings. In view of the massive bone involvement, it was decided that radiation therapy alone was inappropriate. Because the patient had not been on hormone modification therapy previously, prognosis for survival over several years was good, once such therapy was commenced.
Fig 1
Radiographs of extensive involvement of femur by tumor and pathologic fractures in the left lateral femoral condyle.
She underwent resection of the entire femur, knee joint, and proximal 12cm of tibia and fibula in September 1999. A Kotz modular prosthesis including the hip joint, femur, knee joint, and proximal tibia was inserted (fig 2). A hip capsular reconstruction was performed around the neck of the femoral component of the prosthesis using an autologous hip capsule. The gluteus-vastus sling was attached to the prosthesis with a polyethylene fixation plate and self-tapping screws. The short external rotators of the hip were sutured to the gluteus medius. Distally, the patellar tendon was reattached to the proximal tibial piece of the prosthesis and protected with a medial gastrocnemius flap sutured to the patellar tendon and anterior compartment muscles. The hamstrings and lateral intermuscular septum were sutured to the reflected vastus muscles in the thigh. She had a course of adjuvant radiotherapy to the pelvic disease in the early postoperative period. This delayed her transfer to the rehabilitation unit by about 2 weeks.
Fig 2
Kotz modular prosthesis. (A) Proximal femoral component including hip joint and (B) distal femoral and proximal tibial components including knee joint.
She was transferred to the rehabilitation unit about 4 weeks after surgery. To protect the various muscle reattachments, the surgeon advised the following restrictions: “…no active flexion of the knee, wear a Zimmer splint (a knee orthosis with posterior, medial, and lateral malleable bars and anterior Velcro straps to hold the knee in full extension) at all times including during hydrotherapy, no active abduction of the hip or active straight-leg raise.” On admission, the patient was able to walk 10m with a forearm support frame and was allowed to take full weight on the operated leg. Active dorsiflexion at the left ankle was lacking due to peroneal nerve palsy and required a polypropylene ankle-foot orthosis. Physiotherapy commenced with isometric quadriceps and gluteal exercises; active assisted ROM exercises for the left ankle, gentle calf and adductor stretches of the left leg, and right lower-limb strengthening exercises. Hydrotherapy could not be initiated during the first 2 weeks because there was a superficial methicillin-resistant Staphylococcus aureus colonization in the knee wound. After this period, exercises in the pool were performed with a Zimmer splint around the knee. They included left hip extension; toe raises, and ankle ROM exercises; walking forward; walking backward; and general strengthening and fitness work for the right lower limb and the upper limbs.
At around 6 weeks after surgery, she was permitted to start flexing the left knee and this was included in her exercise program. In addition to the gymnasium program she had practice on stairs and in outdoor mobility. The occupational therapist assisted with self-care tasks retraining, car transfers, and carried out a home visit with the patient. The patient lived in a multilevel apartment where several adaptations were required, such as handrails on stairs, over-toilet aid to raise the height of the toilet seat, grab rails in the bathroom, and a 50cm high chair with arms. She was discharged home after 5 weeks. At that time, she could walk independently on elbow crutches and could mange stairs with supervision. The patient continued her rehabilitation on a day-only basis for another 12 weeks. On discharge from this program she was independent with 1 cane (walking stick) and had achieved active hip ROM of 0° to 90° of flexion, 30° of abduction, 20° of adduction, 15° of internal rotation, 30° of external rotation, and active knee ROM of 0° to 85°.
Two years after the total femur replacement she is able to walk up to 800m with either 1 or 2 crutches. While walking without aids she has trunk sway, which is almost inevitable given the need for hip abductor reattachment to the prosthesis. ROM is nearly normal at the hip and 0° to 85° at the knee, with no instability.
Discussion
The first report on cadaveric bone allograft transplantation of the femur in humans dates back to Lexer14 in 1908. In 1966, Ottolenghi15 described a “very satisfactory” result in a 38-year-old woman with extensive hydatid disease in the femur who underwent replacement of the entire femur with a cadaveric bone. Allograft replacement of major bones provides for healing of the host bone by a creeping resubstitution process. Allograft surgery, however, is prone to several complications such as fractures, infection, nonunion, resorption, and articular surface degeneration. Moreover, a cast or brace immobilization is required and weight bearing is limited for long periods. Buchman16 performed the first endoprosthetic total femur replacement on a 24-year-old woman in 1952. He used a custom-made vitallium femur with a hinged proximal tibia. In 1990, Present and Kuschner17 reported a 35-year follow-up study of this earliest reported case of total femur replacement. The patient had been able to “ambulate with a walker” for over 30 years, but required a hip disarticulation amputation in 1984 for intractable leg pain and a draining sinus.
Cemented endoprostheses for replacement of distal or proximal femur have been used for many years. Cementless diaphysial fixation has now become more popular because many tumor patients are young and long-term reliability of these implants is an important issue. Surgical procedures for limb salvage in patients with primary or secondary tumors of major bones in the lower extremity have evolved rapidly over the last 2 decades. In 1986, Kotz et al2 described a 26-piece modular Co-Cr-Mo alloy system for the reconstruction of bones of the lower extremity from the femoral head to the distal third of the tibia. Their series of 52 patients included 2 patients with total femur replacement. Morris et al1 reported excellent or good outcomes in 7 patients who underwent total femur replacement with the Kotz prosthesis. They summarized 8 previous reports, published to that date, on a total of 146 patients who had undergone total femur replacement with different types of prostheses. Nerubay et al18 reported on 19 patients (avg age, 20y) with sarcoma of the femur treated with total femur replacement. They used a stainless steel endoprosthesis with a Thompson femoral head and a long stem (without a knee joint) that is inserted into the medullary canal of the tibia. They emphasized that this design without a knee joint allowed early rehabilitation with the patients being able to walk with full weight bearing at 1 week with a walker or crutches and no external support by 4 weeks.18 Ward et al10 described 21 patients after total femur replacement. Patients ranged in age from 11 to 91 years (mean, 44.6y) and had a mean follow-up period of 23 months. Patients younger than 60 years obtained a greater degree of active ROM when compared with those over 60, on hip flexion (66° vs 43°) and knee flexion (81° vs 49°). They concluded that younger patients are more likely to achieve ambulation without walking aids, whereas older patients will generally continue to require some form of walking aids.10
Indications for total femur replacement include extensive involvement of the femur with high-grade malignant neoplasm such as sarcoma (stage IIB) or metastatic disease or as a salvage procedure after failure of previously inserted prosthesis due to loss of fixation, infection, or fracture.
Both patients in our report had insertion of the Howmedica Modular Resection Systema(fig 3), which is an updated version of the Kotz Modular Femur and Tibia Reconstruction System. All the bone replacement parts on this system have a madreporic finish, which provides a site for extracortical bone bridging and soft tissue attachment.
Fig 3
Howmedical Modular Resection System prosthesis. Components of the prosthesis (from top to bottom): proximal femur and hip, modular shaft piece, distal femur, and proximal tibia.
A program of interdisciplinary rehabilitation is critical for achieving an optimal outcome after total femur replacement. This should be initiated as soon as possible after the surgery. The process of rehabilitation after massive surgery involving replacement of the entire femur and major joints is influenced greatly by surgical factors such as the type of prosthesis, the extent of excision of major muscles such as the quadriceps, hamstrings, and glutei, and the method of reattachment of muscles. Advice from the surgeon about these factors is therefore critical in providing an appropriate program for each patient. In some patients, full weight bearing may not be permitted for several weeks. During this period, the patient is instructed in physiotherapy to ambulate with weight through the contralateral lower limb and the upper limbs, using a forearm support frame or crutches and exercises in a hydrotherapy pool. Initially the patient undertakes isometric muscle exercises, passive or active assisted ROM exercises, and appropriate hydrotherapy exercises. Mobilization is progressed gradually from forearm support frame to rollator frame or crutches and eventually to canes, as muscle strength increases. To minimize the risk of hip joint dislocation, active flexion beyond 90°, hip adduction, and internal rotation movements are not permitted for the first 10 to 12 weeks. Patients will initially require assistance for transfers and most self-care activities. Occupational therapy is provided to retrain the patient in these activities and to assess appropriate equipment such as a long-handled reacher, toilet seat raise, shower chair, and appropriate seating. A home visit with the patient by an occupational therapist is very useful for arranging appropriate modifications, such as grab rails for safety in the bathroom, before the patient returns home. After discharge from inpatient care, patients may require additional help for tasks such as cooking, cleaning, and shopping. This is arranged by the social worker in consultation with the patient and the family.
Patients with total femur replacement differ from those with total hip or knee replacement because their surgery inevitably involves excision of several muscles and subsequent reattachment of the remaining muscles. They will often have restriction on bearing weight to allow incorporation of allograft bone and may not be permitted certain exercises such as active hip abduction or knee flexion for several weeks. They may therefore require a period of 6 to 8 weeks in the rehabilitation unit. The duration of rehabilitation as an inpatient is also affected by several factors other than the surgery, including the patient’s age, comorbid conditions, need for chemotherapy or radiotherapy, and psychosocial factors. The goal prior to discharge is to have the patient achieve a safe level in ambulation and self-care, given the assistance available at home. After discharge, patients will generally need to continue physiotherapy and hydrotherapy for several weeks to further strengthen the muscles and obtain an optimum level of function.
Conclusion
The broad principles of rehabilitation after total hip and total knee arthroplasty are applicable in patients after total femur replacement. These patients, however, present some special challenges because the surgery involves excision of large portions of several muscles, reattachment of these muscles, and replacement of the hip and knee joints. A close liaison with the surgeon regarding specific restriction of active movements or weight bearing is essential. The exercise program needs to be modified to accommodate restrictions such as no active hip abduction or knee flexion to protect muscular reattachments for several weeks. With an appropriate rehabilitation program, patients with total femur replacements can achieve satisfactory ROM at the hip and knee and a high level of functional independence.
aSuppliersHowmedica Modular Resection System; Stryker Howmedica Osteonics, 59 Rte 17S, Allendale, NJ 07401.
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