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Physical therapy management of a patient following external hemipelvectomy due to recurrent local chondrosarcoma.

Introduction

Three major histological types of bone cancer have been described: osteosarcoma arises in the growing ends of long bones, chondrosarcoma (CS) arises in cartilage, and Ewing sarcoma arises in the axial skeleton. (1) CS can arise spontaneously in previously normal bone, (2) or from malignant changes in pre-existing non-malignant lesions (osteochondroma/ enchondroma), (2,3) and is most likely to occur in the pelvis. (2,4) Caucasian men aged 40-60 yrs are more likely to be diagnosed with CS than any other population, (1,2) and the relative survival rate in the United States is 78.5% after ten years. (1)

Patients with CS present with a number of signs and symptoms, but pain is the most common presenting symptom. These tumors are often slow growing and therefore can exist for years without detection or presentation of pain; (2,5) thus they can become quite large. (5) A red flag related to CS is constant pain that increases with weight bearing, and is independent of activity or position. (2) Other signs and symptoms related to primary bone tumors are night pain, swelling, fever, and a presence of a mass. (2) Medical differential diagnosis of CS is complicated and requires histological differentiation among many types of tumors (refer to review paper by Pring for a more detailed discussion.) (3)

Treatment options are limited due to the large size of the tumors and their destructive nature prior to discovery. Surgical excision is complicated by the involvement of large vessels and nerves; (5,6) radiation and chemotherapy are ineffective due to the slow growing nature of the tumor cells. (2-5) The most reliable treatment is complete wide margin surgical resection. (2-5) Unfortunately, local recurrence is frequent, (5) and the recurrent lesions are often more difficult to treat, resulting in a poor prognosis. (4) Pelvic tumors have a higher rate of recurrence than similarly graded tumors in long bones, and consequently have an adverse effect on the rate of survival. (3)

An external hemipelvectomy (HP) is defined as the surgical removal of the entire lower extremity through the sacroiliac and the pubic joints. (7,8) Indications for external HP are severe crushing or shearing trauma to the pelvis; (9) recurrent severe ulcerations/infections in a patient with a spinal cord injury; (9) and various pelvic cancers that involve two of the three following structures: femoral neurovascular bundle, (3,4) lumbosacral plexus, (3,4) and/or the hip joint. (3) Improved use of imaging, advanced surgical techniques, and a greater understanding of appropriate margins necessary for complete surgical resection has allowed for a greater percentage of successful limb-salvage procedures, helping some patients avoid an external HP. (3)

HP surgeries are typically complicated, and as much as seventy-seven percent of patients experience at least one peri-operative complication, with flap necrosis being the most common. (10,11) Thirty-three percent of all patients who undergo the surgery do not survive the procedure, (9) and those who do survive face significant functional limitations. (10) Even with aggressive surgery, long-term survival is only fifty percent with recurrent CS tumors. (4)

Case Description

This case report describes the physical therapy examination, evaluation, diagnosis, prognosis and intervention for a patient who underwent a right external hemipelvectomy secondary to CS. A functional outcome measure and principles of evidence based practice were also incorporated into management of this patient.

Examination

History: The patient was 76-year-old Caucasian man who was diagnosed with type 2 pelvic CS after experiencing symptoms of right anterior hip pain, which he initially attributed to a pulled muscle. Two years later, the patient underwent surgical resection of the right pelvic CS tumor, placement of a pelvic allograft to fill the void, and a right hip joint replacement. The patient never regained the ability to fully bear weight on the right (R) lower extremity (LE) and required the use of a four wheeled walker. Despite this impairment, the patient was able to attain a high level of functional mobility, illustrated by his ability to drive, perform all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) independently, as well as live alone in a retirement community apartment.

Five years after his initial surgery, the patient underwent a screening bone scan to monitor the status of the CS tumor location; at this time, the results were negative for tumor recurrence. A year later, the patient experienced an increase in right pelvic pain and again met with his oncologist. At that time, a softball sized mass was discovered in the right pelvic region; it displaced all of the ileum, and was growing over the sacrum. This mass was determined to be a recurrent local grade 2 CS tumor. Allograft dissolution along with the majority of the superior/ anterior pubic rami and the pubic symphysis were also discovered at this time. Six years after his initial tumor resection surgery (eight years after initial onset of symptoms), he was determined to be a candidate for a right external hemipelvectomy.

To remove the tumor, surgeons had to cut through the dorsal aspect of the sacrum and the transverse processes of [L.sub.4] and [L.sub.5]. The surgical team reported a possible intra-operative myocardial infarction, and the patient experienced post-surgical hemorrhagic and hypovolemic shock, in addition to acute respiratory failure requiring mechanical ventilation. The tumor encroached on the inferior vena cava and right common iliac vein, which resulted in a blood loss of approximately six liters. The patient spent his first three post operative days (POD) in the intensive care unit (ICU). He required placement of a left femoral central line and left femoral arterial line while in the ICU to allow for adequate management of his various medical complications.

The patient experienced a number of urological complications including renal insufficiency, urinary retention, multiple urinary tract infections, and was eventually diagnosed with a hypotonic neurogenic bladder, requiring periodic straight self catheterization. He also experienced a variety of gastrointestinal complications including the inability to produce a bowel movement without suppositories and digital stimulation, and gastroesophageal reflux. He was eventually diagnosed with a neurogenic bowel also, due to absent rectal sphincter tone and absent bulbocavernous reflex.

The patient experienced a variety of other complications: significant scrotal swelling, anesthesia in the right groin, generalized weakness, fatigue, and wound healing complications. On POD11 he underwent a post surgical CT scan of the abdomen/pelvis to determine the status of the tumor; a small soft tissue mass was discovered in the right hemipelvic area, and was described as either a recurrent tumor, or a portion of the original tumor missed during the resection.

Systems Review:

Communication: Unimpaired.

Cardiovascular: Impaired. Venous ultrasound results indicated the patient had multiple deep vein thrombi (DVTs) in distal portions of the left brachial, basilic, and cephalic veins.

Integumentary: Impaired. The patient developed a small sacral pressure ulcer and experienced skin breakdown at the surgical site, requiring surgical debridement on POD15. The physician prescribed an air bed as a preventative measure for development of further pressure ulcers, and to prevent worsening of the current skin compromise at the surgical site.

Musculoskeletal: Impaired. The patient had difficulty maintaining a proper sitting posture due to the loss of the weight-bearing surface of the (R) ischial tuberosity. The patient slouched and shifted toward the left during initial sitting to avoid any pressure on the surgical site and in an attempt to reduce pressure on his significantly swollen scrotum. He demonstrated a forward head and rounded shoulders during sitting and when attempting to stand. He also demonstrated generalized weakness secondary to the surgery, complicating events, and eight days of post-surgical bedrest.

Neuromuscular: Impaired. The patient initially had great difficulty with all transfers and required maximal assistance of two or more people for all activities. He demonstrated fair static sitting balance using the functional balance grading scale, (13) and could sit at the edge of the bed for twelve minutes but required bilateral (B) UE support and two people providing close contact guard assistance. The patient had poor dynamic sitting balance due to his inability to move outside his base of support. (13) At initial examination, the patient was unable to stand and therefore static and dynamic standing balance could not be rated.

Tests and Measures: At the time of initial physical therapy examination, POD7, the patient was significantly limited in all aspects of functional mobility.

Gait and Locomotion: The patient was neither able to perform wheelchair (WC) propulsion, nor was he able to stand independently with or without an assistive device. He required maximum assistance from two people for bed mobility, and transfers from supine to sitting, and sitting to supine. The patient required maximum assistance from three people to transfer from sitting at the edge of bed to standing, and to perform a stand pivot transfer to the commode. He was unable to transfer onto a bath bench or sit in a chair at the time of initial examination.

Range of Motion: The patient's range of motion was within functional limits for bilateral (B) upper extremities (UE) and the (L) LE. Strength: He demonstrated considerable weakness in the abdominal and back extensor musculature secondary to the loss of attachment availability from removal of the right pelvic structures. This deficit was exhibited by poor trunk control and difficulty effectively pulling his trunk into a fully upright position. The patient's (B) UE strength was within functional limits, but due to the new demands required for ambulation and propulsion of a wheelchair, he required increased strength and muscular endurance to allow for greater efficiency during locomotion. His (L) LE strength was within functional limits for most muscle groups, but moderate weakness (grade 3/5) was discovered in the (L) hip flexors and extensors. This measured weakness was likely related to his limited ability to stabilize his trunk/pelvis during manual muscle testing.

Functional/Disability Outcome Measure: The Functional Independence Measure (FIM), used to estimate the burden of care necessary for an individual, was used to track the functional recovery of this patient. The instrument rates individuals on a spectrum ranging from total dependence to complete independence, with lower scores indicating greater dependence. (13) The FIM is used in many rehabilitation facilities across the country and has been shown to have a test-retest reliability of 0.93, and inter/intra-rater reliabilities of 0.94. (13) This patient initially scored 50 out of a possible 126 points.

Evaluation, Diagnosis & Prognosis

Evaluation: This 76 year old patient was significantly limited in all aspect of his functional mobility, including ADLs, IADLs, and other important life areas such as recreation and hobbies. These limitations were due to significant anatomic changes resulting from the right external HP secondary to CS, and other peri/post-surgical complications.

Diagnosis: This patient's primary physical therapy diagnosis is musculoskeletal practice pattern 4J: impaired motor function, muscle performance, range of motion, gait, locomotion, and balance associated with amputation. (14)

Prognosis and Plan of Care: This patient should attain functional independence and the ability to live independently following an intensive course of physical rehabilitation. The patient would likely use a WC as his primary mode of community mobility, and a front wheeled walker (FWW) in the home, but may use a FWW for community mobility following intensive strength and endurance training.

Anticipated Goals and Expected Outcomes

This patient was followed through his acute care stay, and then periodically during his stay at a skilled nursing facility (SNF) associated with the acute care hospital. The following anticipated goals (AG) were established during his acute stay. AG1: Patient will tolerate sitting upright in a chair for 15 minutes for participation in UE strengthening within three days. AG2: Patient will safely propel WC 100 feet with contact guard assistance to increase aerobic activity tolerance within 5 days. AG3: Patient will tolerate sitting on commode for 5 minutes within 3 days.

The following expected outcomes (EO) were determined during his acute stay. EO1: Patient will be independent with bed mobility to decrease the development of skin ulcerations within 2-3 weeks. EO2: Patient will ambulate 150 feet safely using FWW within 2-3 weeks to work toward functional ambulation within his home. EO3: Patient will tolerate sitting on a commode for 10 minutes (to produce a bowel movement) within 2-3 weeks. EO4: Patient will tolerate sitting upright in chair with specialized cushion for 30 minutes to allow independence with select self care activities within 2-3 weeks. EO5: Patient will achieve a FIM score of 112 points (compared with 50 points at initial exam) at SNF discharge.

The patient identified a number of personal goals (PG). PG1: Patient will drive his vehicle with appropriate pedal adaptations for use with left foot. PG2: Patient will ambulate within the community using his four-wheeled walker by the end of his SNF stay. PG3: Patient will return to prior level of function (ADLs and IADLs) within his apartment by the end of his SNF stay.

Intervention

The patient received a total of fourteen physical therapy sessions during his acute stay; each lasting from 30-60 minutes dependent on patient tolerance. The majority of interventions focused on functional training in order to increase the patient's independence and quality of life. The patient was instructed in strengthening exercises for the (R) LE and (B) UEs using open and closed chain exercises while in bed and sitting in his WC. Bed mobility training was provided to allow for independent repositioning in order to preserve skin integrity, comfort, and more efficient dressing changes. The patient participated in transfer training to and from the WC, commode, and bed, as well as seated self-care activities, and seated and standing balance exercises.

The patient performed WC propulsion to develop aerobic tolerance, strength and muscular endurance of the UEs, and further focus on surgical site weight bearing tolerance. He was provided with a custom cushion, (Figure 1) carved from a standard abduction wedge. This cushion was used to improve sitting and weight bearing tolerance by decreasing discomfort at the surgical site, to provide improved postural support, and to prevent the development of functional scoliosis. (15,16) The patient also participated in frequent ambulation on varied level surfaces with a FWW and contact guard assistance (CGA) from two people. He was educated about the importance of maintaining an active lifestyle and spending as much time as possible in an upright position to accelerate the rate of weight bearing tolerance at the surgical site and to improve his cardiopulmonary system function.

[ILLUSTRATION OMITTED]

Outcomes

This patient made dramatic functional improvement in all areas assessed during the initial physical therapy examination (on POD 7). Initially, the patient was unable to perform any functional activities independently, but by the end of his acute care stay (POD 22) he performed most transfers with only contact guard to minimal assistance, and was independent with all transfers by the end of the SNF stay (POD 42), when he was discharged to home. Table 1 illustrates improvements in activity limitations between initial examination and facility discharge.

The patient continued to use his custom carved cushion at the SNF for all sitting activities, and reported he could sit for 30 minutes at a time with the cushion compared with only 5-10 minutes without. He was discharged home with the following equipment: standard weight sling-back style folding WC for traveling distances greater than 400 feet, FWW for household ambulation and limited community ambulation distances, overhead trapeze (patient preferred this equipment instead of a hospital bed) for independent transfers and bed mobility, adaptive equipment (reacher, sock aid) for self care and dressing, and a bath chair. Once the surgical site fully healed, the patient would be fitted for a permanent customized WC seating system.

The patient was scheduled to receive home health physical and occupational therapy to continue improvement of aerobic endurance, total body strength, balance, sitting tolerance, ambulation, and independence with ADLs/ IADLs. The patient would also have periodic assistance from a caregiver for bathing, household cleaning, meal preparation, grocery shopping, and transportation to medical appointments.

Discussion

Current research on the topic of patient rehabilitation following external HP is limited, but a few case reports from the 1950's and 1960's, and a few articles from more recent years do exist. The most comprehensive description was published in 1953, and outlined the rehabilitation of a 31 year-old male post external HP. (7) The authors suggested that a full body strengthening and cardiovascular conditioning program must be initiated to reverse the effects of the extended time required for post-surgical recovery. (7)

Due to the drastic changes in body composition and functioning following HP and subsequent recovery, emphasis is placed on teaching patients skills in bed mobility, transfers, and an appropriate mode of locomotion. (17) According to a series of articles published in 2005, "three vital skills" must be addressed in physical therapy: independent transfers, independent sit to stand, and ambulation of at least 25 feet within the parallel bars or with a walker. (9,15,18) Authors also note that interventions to improve sitting tolerance (15) and balance (7,15) must be a focal point of the rehabilitation plan of care, as they were for the patient described in this paper. Other important rehabilitation interventions such as balance activities to teach patients to compensate for severe alterations in the center of mass, (19) prosthetic training, (7,20) creation of a customized seating system, (16,18) and optimization of lower extremity function (7) have been described in the literature as well.

Hemipelvectomy surgery has a profound effect on patients in multiple systems and areas of function. The Integumentary, neuromuscular and musculoskeletal systems are directly impaired due to the surgery. Specifically, the risk for development of pressure ulcers is increased due to altered weight bearing surfaces, significant negative impact on sitting tolerance and sitting balance, disruption of symmetry and center of mass, and a considerable impact on self image. (9)

Further, the cardiopulmonary system typically becomes impaired due to the relative immobility associated with intensive care unit stays and medical management of post-surgical recovery. The resultant deconditioning can limit endurance for participation in rehabilitation interventions, and lead to greater lengths of stay in acute care and other skilled settings. For example, this patient was in the acute care hospital for 22 days, followed by 20 days in a SNF, for a total of 42 days of care required following external HP surgery.

Ambulation with a HP prosthetic device is possible, (7-10,17,19,21,22) but the difficulty of mastering this task, especially without an assistive device, is amplified as age advances. (15) Use of a HP prosthesis for full time ambulation is unlikely for a patients over the age of 60. (15) Older patients are more likely to use a WC or single limb swing-through gait with a walker as their primary modes of locomotion. (15) This patient, who was 76 years old, was able to ambulate 400 feet with a FWW and single limb gait at the time of facility discharge.

The FIM was used to track this patient's functional recovery, with an initial score of 50 points, and an expected outcome of 112 points. His final score FIM score was 109, evidence of a dramatic improvement in his level of functional independence following physical therapy intervention. He was three points short of the predicted goal score due to three areas of deficit. He lost one point because he needed a reacher for lower extremity dressing at discharge, which had not been anticipated. He lost another point because he was unable to negotiate door sills, carpet bumps and a 3% grade incline while in his WC. The patient lost another point due to his inability to manage an entire flight of stairs. This limitation did not receive priority in intervention planning, because the patient had no immediate need to use stairs to access his home. This dramatic improvement in function was considered a success, as the patient was able to return to his home following facility discharge. Further, he was scheduled to receive home health physical therapy, and therefore would have the opportunity to continue to make measurable functional gains.

One of the most beneficial interventions provided for this patient was the custom carved seat cushion, which allowed for increased tolerance for seated activities and eventually made sitting during meals and recreational activities possible. This "temporary" cushion traveled with the patient to the SNF and was taken home to be used until a more permanent seating solution was devised. Utilizing the sitting functional reach test, recently published by Thompson and colleagues, (23) may have been helpful to provide another functional outcome measurement. This instrument provides an objective measure of change in dynamic sitting balance (forward and lateral sitting functional reach), and allows for comparison to normative data for patients of similar ages. (23) Finally this patient may have responded positively to multiple visits daily, but physical therapy staffing in the facility was limited, resulting in the patient typically receiving a single physical therapy visit six to seven days a week.

Conclusion

This patient case report described the elements of physical therapy management for a patient with right external HP due to recurrent local chondrosarcoma. The description followed the APTA's Guide to Physical Therapist Practice in outlining the physical therapy examination, evaluation, diagnosis, prognosis, and intervention for this patient. (14) A functional outcome measure and principles of evidence-based practice were also incorporated into management of this patient.

This patient population may seem intimidating due to multiple system involvement and high risk of post-surgical complications. However, this patient made significant functional improvements over his episodes of care in the acute care and SNF settings with physical therapy intervention, despite his advanced age and the detrimental effects of prolonged bed rest and massive anatomical alterations due to external HP surgery.

References

(1.) Lewis DR, Ries LAG. Cancers of the bone and joint. In: Ries LAG, Young JL Jr., Keel GE, Eisner MP, Lin YD, Horner MD, eds. SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. Bethesda, MD. National Cancer Institute, SEER Program. 2007:81-88.

(2.) Goodman CC. The Respiratory System. In: Allen A, Waltner P, eds. Pathology Implications for the Physical Therapist. 2nd ed. Philadelphia, Pa: Saunders; 2003.

(3.) Pring ME, Weber KL, Unna KK, Sim FH. Chondrosarcoma of the pelvis: a review of sixty-four cases. J Bone Joint Surg. 2001;83:1630-1642.

(4.) Weber KL, Pring ME, Sim FH. Treatment and outcome of recurrent pelvic chondrosarcoma. Clin Orthop. 2002;397:19-28.

(5.) Donate D, El Ghoneimy A, Bertoni F, et al. Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg. 2005;87B:1527-1530.

(6.) Mankind HJ, Cornice FJ. Internal hemipelvectomy for the management of pelvic sarcomas. Surg Oncol Clin N Am. 2005;14:381-396.

(7.) Painter CW, von Werssowetz OF. Prosthetic training of a hemipelvectomy patient. Phys Ther Reviews. 1953;33:10-16.

(8.) Lewis C. Postoperative outcomes of internal and external hemipelvectomies: a literature review. Rehab Oncology. 2002;20:10-12.

(9.) Smith DG. Higher challenges: the hip disarticulation and transpelvic amputation levels. In Motion. 2005;15:48-53.

(10.) Hillmann A, Hoffmann C, Gushier G, et al. Tumors of the pelvis: complications after reconstruction. Arch Orthop Trauma Surg. 2003;123:340-344.

(11.) Baliski CR, Schachar NS, McKinnon G, et al. Hemipelvectomy: a changing perspective for rare procedure. Can J Surg. 2004;47:99-103.

(12.) O'Sullivan SB. Physical Rehabilitation: Assessment and Treatment. 4th ed. Philadelphia, PA: F.A. Davis Company;2001.

(13.) Finch E, Brooks D, Stratford PW, Mayo NE. Physical Rehabilitation Outcome Measures: A Guide to Enhanced Clinical Decision Making. 2nd ed. Hamilton, Ontario Canada: BC Decker Inc; 2002.

(14.) Bomert J, Moffat M, Zadai C, eds. Guide to Physical Therapist Practice. 2nd ed revised. Alexandria, VA: American Physical Therapy Association; 2003.

(15.) Smith DG. Higher challenges: amputations at the hip and pelvis, part 2. In Motion. 2005;15:50-55.

(16.) Skoski C. The pelvic leveler: an alternative to a sitting socket. In Motion. 2005;15:54-55.

(17.) Palgi K. Acute and subacute physical therapy management for a patient status post external hemipelvectomy due to chondrosarcoma of the pelvis: a case report. Rehab Oncology. 2005;23:20-23.

(18.) Smith DG. Higher challenges: the hip disarticulation and transpelvic amputation levels, part 3. In Motion. 2005;15:38-42.

(19.) Churchill CJ, Simon Etta RJ, Lyford J, Muss I. Postoperative "restoration" of the hemipelvectomized patient. J of Kentucky State Medical Association. 1957;55:904-906.

(20.) von Werssowetz OF, Painter CW. Physical rehabilitation of a hemipelvectomy amputee. Annals Surg. 1953;137:395-398.

(21.) Nowroozi F, Salvanelli ML, Gerber LH. Energy expenditure in hip disarticulations and hemipelvectomy amputees. Arch Phys Med Rehab. 1983;64:300-303.

(22.) Watkins AL. Rehabilitation after hemipelvectomy. JAMA. 1962;181:131-132.

(23.) Thompson M, Medley A. Forward and lateral sitting functional reach in younger, middle-aged, and older adults. J Geriatr Phys Ther. 2007;30:43-48.

Kendra Aikenhead, PT, DPT & Kimberly K. Cleary, PT, PhD

Kendra Aikenhead, PT, DPT graduated from Eastern Washington University's Doctor of Physical Therapy Program. She is currently practicing in outpatient physical therapy and the school district settings in Elko, Nevada.

Kimberly Cleary, PT, PhD is Associate Professor of Physical Therapy at Eastern Washington University in Spokane, WA. You may contact Dr. Cleary at kcleary@ewu.edu.
Table 1: Activity Limitations at Initial Examination and Facility
Discharge.

Activity Limitations        Initial Examination   Facility Discharge

Bed mobility                Dependent             Independent (with
Supine [left and right                            overhead trapeze)
arrow] sit transfer
Transfers                   Dependent             Independent
Sit [left and right
arrow] stand; Stand
pivot [left and right
arrow] chair, commode,
bath bench
Ambulation                  Unable                Independent 400'
                                                  with FWW
                                                  (short seated rest
                                                  at 200')
Wheelchair propulsion       Dependent             Independent 400'
                                                  over flat surfaces
ADLs                        Dependent             Independent
Sitting tolerance           12 mins. using (B)    30 mins. using
                            UE for support        custom cushion and
                                                  intermittent support
                                                  from (B) UE
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Author:Aikenhead, Kendra; Cleary, Kimberly K.
Publication:Acute Care Perspectives
Article Type:Report
Geographic Code:1U8NV
Date:Jun 22, 2009
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