Rehabilitation Protocols and Functional Outcomes in Oncological Patients Treated with Modular Megaprosthesis: A Systematic Review
Simple Summary
Abstract
1. Introduction
2. Materials and Methods
3. Results
3.1. Study Characteristics
3.2. Performed Operations, Morbidity and Mortality Outcomes
3.3. Rehabilitative Protocols and Functional Outcomes
3.3.1. Shoulder Reconstruction
3.3.2. Hip Reconstruction
3.3.3. Knee Reconstruction
3.4. Study Quality Assessment
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
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Author Year Country | Study | Surgical Indication | Number of Participants (Male: Female Ratio) Mean Age (Years) | Follow-Up Period (Months) | Mortality Outcomes Morbidity Outcomes Other Outcomes |
---|---|---|---|---|---|
Proximal humerus | |||||
Shehadeh et al. 2013 [11] Jordan | Retrospective | Primary bone tumour | 59 (32:27) * 11 patients eligible 24 | 24 | No mortality data No infection rate data |
Raiss et al. 2009 [12] Germany | Prospective | Primary tumour and metastatic disease | 39 (19:20) 60 | 38 | Mortality rate was 10% at 11.5 years 5% of patients had deep wound infections 10% prosthesis dislocation rate |
El Motassime et al. 2023 [13] Italy | Retrospective | Metastatic disease | 20 (12:8) 61.5 | 21 | 17.9% mortality rate at 6 months 10% prosthesis dislocation rate No infection data reported. |
Guven et al. 2016 [14] Turkey | Retrospective | Primary bone tumour and metastatic disease | 10 (5:5) 49.4 | 18.2 | 20% mortality rate at 6 months No infections recorded 20% prosthesis dislocation rate |
Trovarelli et al. 2019 [15] Italy | Retrospective | Primary tumour | 22 (9:13) 55 | 36 | 22.7% mortality rate at 22 months Aseptic loosening in 4% of patients No infections recorded. 18% prosthesis dislocation rate |
Distal Humerus | |||||
Casadei et al. 2016 [16] Italy | Retrospective | Primary bone tumour and metastatic disease | 47 | 35 | 31.9% mortality rate at 35 months 4% wound infection rate |
Proximal and Total Femur | |||||
Shehadeh et al. 2013 [11] Jordan | Retrospective | * Total femur and proximal femur Primary bone tumour. | 59(32:27) * 6 patients eligible 24 | 24 | No available mortality data. No infection rate data. |
Vitiello et al. 2022 [17] Italy | Retrospectively | Proximal femur Metastatic disease | 25 (10:15) 67.5 | 30.5 | No available mortality data. No infections noted. Other infections: cystitis 8%, pneumonia 8%. 4% prosthesis dislocation rate |
Kamiński et al. 2017 [18] Poland | Retrospective | Proximal femur Metastatic disease and implant revision | 34 (7:6) 68.5 | 18 | 11.7% mortality rate at 12 months 0 reported surgical site infections 15% prosthesis dislocation rate |
Andreani et al. 2024 [19] Italy | Retrospective | Proximal femur Primary bone tumour and metastatic disease | 22 (missing ratio) 58.9 | 44 | No available mortality data. 4% superficial wound infection rate 4% prosthesis dislocation rate |
Ziranu et al. 2022 [20] Italy | Retrospective | Proximal femur Metastatic disease | 35 (12:23) 72 | 34.5 | 4% mortality rate at 2 years 50% periprosthetic joint infection 25% prosthesis dislocations and tendon ruptures |
Ruggieri et al. 2010 [21] Italy | Retrospective | Total femur Primary bone tumour | 21 (15:6) 21 | 120 | 55% mortality rate at 10 years 14% periprosthetic joint infection 4% prosthesis dislocations |
Pitera et al. 2017 [22] Poland | Retrospective | Proximal femur Primary bone tumour and metastatic disease | 42 (19:23) 63 | 1.5 | No available mortality data No available wound infection rate 2% prosthesis dislocation rate |
Distal Femur and Proximal Tibia | |||||
Shehadeh et al. 2013 [11] Jordan | Retrospective | Proximal tibia Primary bone tumour | 59(32:27) * 8 patients eligible 24 | 24 | No mortality data. 37.5% infection rate |
Shehadeh et al. 2013 [11] Jordan | Retrospective | Distal femur Primary bone tumour | 59(32:27) * 21 patients eligible 24 | 24 | No mortality data. No infection rate data. |
Andreani et al. 2023 [23] Italy | Retrospective | Distal Femur Primary bone tumour and metastatic disease | 16 44.1 | 46.7 | No mortality data. 6.25% wound infection rate |
Study | Rehabilitation Protocol | Functional Outcomes |
---|---|---|
Shehadeh et al. 2013 [11] Jordan | Days 1–10: Arm in sling (or immobiliser). Start hand and elbow exercises. Day 10: Take off arm sling for gentle Codman I/II shoulder exercises. Start elbow full extension exercise after week 4. 6 weeks of AAROM shoulder. | MSTS–ISOLS Score: 83% |
Raiss et al. 2009 [12] Germany | Day 1: Arms placed in internal rotation in Gilchrist bandages for 6 weeks, shoulder mobilised passively for 6 weeks with 60 degrees of shoulder flexion and abduction and 0 degrees of external rotation 6 weeks: unlimited range of motion exercises. | Mean Enneking score: 19 (range: 7–27 points) at last follow-up (38 months) Mean active ROM: shoulder flexion 34° (range: 0–90°), abduction 33° (range: 0–90°), and external rotation 10° (range: 10–50°). |
El Motassime et al. 2023 [13] Italy | Day 1: Brace immobilisation Day 15: Codman exercises and elbow flexion-extension exercises 6 months: brace removal, active ROM exercises. | Mean MSTS score: 57.6% (±26.24) Mean DASH score: 47.5 (±27.55) Mean WOSI score: 950 (58.62%) (±532.29) |
Guven et al. 2016 [14] Turkey | Day 1: Sling immobilisation with an abduction pillow. Passive wrist and elbow exercises. Week 6: Passive shoulder exercises | Mean active flexion: 96° (range, 30–160°), mean active abduction: 88 (range: 30–160°), mean active external rotation: 13° (range: 0–20°). Mean Constant-Murley score: 53.7% (range: 22–96%) Mean DASH score: 26.2 (range: 5.8–60) Mean VAS score: 1.3 (range: 0–4) Mean MSTS score: 78.1% (range: 50–93%) |
Trovarelli et al. 2019 [15] Italy | Day 1: Postoperative 30° abduction brace for 4 weeks. 1 month: active mobilisation with pendulum movements limited to 30° of abduction, forward flexion and extension Week 6–7: isometric exercise to emphasise lower trapezius and serratus anterior activation and reduce upper trapezius activation. | Mean Constant score: 61 (42 to 89), mean normalised Constant score: 66 (48 to 97) Mean ASES score: 81 (range: 62 to 92) Mean MSTS score was 29% (range: 26 to 30) Mean abduction: 103° (range: 40 to 180°), mean flexion: 117° (range: 40 to 180°) and mean external rotation: 58° (range: 45 to 75°) |
Study | Rehabilitation Protocol | Functional Outcomes |
---|---|---|
Casadei et al. 2016 [16] Italy | 0–2 weeks: Arm immobilised in sling. Active and passive finger movement was initiated on the first postoperative day. Week 1: Active elbow movement in cemented prostheses, Week 4: Active arm movements in uncemented prostheses, Week 6–8: Active arm movement in allograft-prosthesis composite | Mean elbow ROM: 70° in patients with primary tumour, 40° in patients with metastasis. Mean MEP score: 84% Mean MSTS score 73% |
Study | Rehabilitation Protocol | Functional Outcomes |
---|---|---|
Vitiello et al. 2022 [17] Rome | Day 2: patients seated with their feet out of bed. Day 3: progressive weight bearing with walker frames. Week 8: All patients walking without aids. | Mean Karnofsky score: 76% (±21) Mean VAS at 1 month, 6 months and 12 months—2.1, 0.5 ± 1.2 and 0.5 ± 0.8, respectively. Mean MSTS at 1 month, 6 months and 12 months—12.3 ± 3.7, 19.2 ± 2.4 and 19.1 ± 5.6, respectively. |
Shehadeh et al. 2013 [11] Jordan | Days 1–3: Limb suspended in abduction (30°) and flexion (30°). Knee and ankle exercises. For the total femur, in addition, the knee is immobilised in knee brace. Day 4: Week 6: The patient is mobilised in a custom abduction brace (locked in 30° abduction and 0–60° hip flexion), toe touch weight bearing started. Abductor muscles strengthening. For the total femur, the knee immobiliser was discontinued at two weeks, and knee flexion exercises started. Week >6–8: Brace is removed (Active hip abduction required before the brace is removed, and full weight bearing is allowed) | Mean MSTS–ISOLS score: 86% |
Kamiński et al. 2017 [18] Poland | Week 0–6: Walking with crutches and partial load. This period was extended to 12 weeks in cases where concomitant acetabular reconstruction prevented the patients from earlier weight bearing. Week >6: Gradually achieve full load on the limb (no later than 4 months after surgery). | Mean VAS score: 3.4 Mean HHS: 70.68 Mean modified Harris Hip Score: 64.25 |
Andreani et al. 2024 [19] Italy | Week 1–2: Hip brace 0–30° for full time. Toe touch weight bearing on the operated leg Week 2–3: Hip brace 0–30° for full time. Partial weight bearing on the operated leg Week 3–4: Hip brace 0–60° for full time. Progressive partial weight bearing on the operated leg Week >4: Hip brace 0–60° (up to 0–90° in selected cases) for full-time for at least 2 months and progressive removal. Full weight bearing on the operated leg. Stair climbing re-education is most intense | Mean MSTS score: 23.2 |
Ziranu et al. 2022 [20] Italy | Day 2: patients seated with their feet out of bed Day 3: Progressive weight bearing with walker frames. Routine total hip precautions were followed for 3 months. | Walking without aids was achieved in 2 months for all patients. |
Ruggieri et al. 2010 [21] Italy | Day 1: Isometric exercises were started the day after surgery. Week 1–4: Immobilisation in a cast. Assisted walking for 6 weeks, supervised by a physical therapist. Week 8: Brace with progressive ROM for a further 2 months. | Mean MSTS: 66% Average knee ROM: 60° (range: 0–110°) |
Pitera et al. 2017 [22] Poland | Days 1–3: The limb is suspended in abduction (30°) and flexion (30°). Knee and ankle exercises are encouraged. For the total femur, in addition, the knee is immobilised in a knee brace. Day 4—week 6—The patient is mobilised in a custom abduction brace (locked in 30° abduction and 0–60° hip flexion), toe touch weight bearing started. Abductor muscles strengthening. For the total femur, the knee immobiliser was discontinued at two weeks and knee flexion exercises start. Week 6–8: Brace is removed. Active hip abduction is required before the brace is removed, and full weight bearing is allowed. | Mean VAS score: 3.8 Mean MSTS score: 66% Mean HHS score: 75 |
Study | Rehabilitation Protocol | Functional Outcomes |
---|---|---|
Shehadeh et al. 2013 [11] Jordan | Distal Femur: Day 1–3: knee immobiliser, start isometric exercises, knee flexion NOT allowed. Bed to chair only. Day 3 to week 2: Start weight bearing as tolerated for cemented prostheses (with knee immobiliser). For cementless prostheses, partial weight bearing (with knee immobiliser). Week 2–6: AAROM knee if skin healed. Discontinue the knee brace. Continue concentration on extensor strengthening. Begin hamstring exercises. Week > 6: Knee flexion exercises and increase the extensor strength. Proximal Tibia: Day 1–5: Rigid knee immobiliser. Allow weight bearing as tolerated. Day 5 to week 6: No active or passive knee flexion. Keep the knee in an immobiliser to allow healing of the patellar tendon. Isometric quadriceps strengthening exercises only. >6 weeks: passive and gentle AAROM knee flexion. | Mean MSTS–ISOLS score: 93% in the distal femur patient cohort Mean MSTS–ISOLS score: 88% in proximal tibia patient cohort |
Andreani et al. 2023 [23] Italy | Week 1–2: Knee brace. Partial weight bearing. Gait re-education, postural passages. Week: 2–3: Progressive weight bearing. Week: 3–4: Full weight bearing. Progressive stair climbing. Week >4: High-intensity stair climbing exercises. Removal of brace at day 30. | Mean MSTS score: 23.2 (range: 12–30) |
Study | Andreani et al. 2024 [19] | Andreani et al. 2023 [23] | El Motassime et al. 2023 [13] | Vitiello et al. 2022 [17] | Ziranu et al. 2022 [20] | Trovarelli et al. 2019 [15] | Kamiński et al. 2017 [18] | Pitera et al. 2017 [22] | Casadei et al. 2016 [16] | Guven et al. 2016 [14] | Shehadeh et al., 2013 [11] | Ruggieri et al. 2010 [21] | Raiss et al. 2009 [12] |
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Were there clear criteria for inclusion in the study? | YES | YES | UNCLEAR | UNCLEAR | NO | YES | UNCLEAR | YES | YES | YES | NO | YES | YES |
Was the condition measured in a standard, reliable way for all participants included in the case series? | YES | YES | NO | NO | NO | NO | NO | YES | NO | NO | NO | YES | YES |
Were valid methods used for the identification of the condition for all participants included in the case series? | YES | YES | NO | NO | YES | YES | NO | NO | YES | YES | NO | YES | NO |
Did the case series have consecutive inclusion of participants? | YES | YES | YES | YES | NO | YES | UNCLEAR | UNCLEAR | YES | YES | YES | YES | YES |
Did the case series have complete inclusion of participants? | YES | YES | NO | YES | YES | NO | NO | UNCLEAR | NO | NO | UNCLEAR | NO | NO |
Was there clear reporting of the demographics of the participants in the study? | NO | NO | YES | YES | YES | YES | YES | YES | NO | YES | YES | YES | YES |
Was there clear reporting of clinical information of the participants? | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES |
Were the outcomes or follow-up results of cases clearly reported? | NO | NO | YES | YES | NO | YES | YES | YES | YES | YES | YES | YES | YES |
Was there clear reporting of the presenting site(s)/clinic(s) demographic information? | YES | YES | YES | YES | UNCLEAR | YES | YES | YES | UNCLEAR | YES | UNCLEAR | YES | YES |
Was statistical analysis appropriate? | YES | YES | NO | YES | NO | NO | NO | NO | NO | NO | NO | NO | NO |
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Brzeszczyński, F.F.; Karpiński, M.; Brzeszczyński, M.A.; Bończak, O.; Hamilton, D.F. Rehabilitation Protocols and Functional Outcomes in Oncological Patients Treated with Modular Megaprosthesis: A Systematic Review. Cancers 2025, 17, 2951. https://doi.org/10.3390/cancers17182951
Brzeszczyński FF, Karpiński M, Brzeszczyński MA, Bończak O, Hamilton DF. Rehabilitation Protocols and Functional Outcomes in Oncological Patients Treated with Modular Megaprosthesis: A Systematic Review. Cancers. 2025; 17(18):2951. https://doi.org/10.3390/cancers17182951
Chicago/Turabian StyleBrzeszczyński, Filip Fryderyk, Michał Karpiński, Marcel Aleksander Brzeszczyński, Oktawiusz Bończak, and David F. Hamilton. 2025. "Rehabilitation Protocols and Functional Outcomes in Oncological Patients Treated with Modular Megaprosthesis: A Systematic Review" Cancers 17, no. 18: 2951. https://doi.org/10.3390/cancers17182951
APA StyleBrzeszczyński, F. F., Karpiński, M., Brzeszczyński, M. A., Bończak, O., & Hamilton, D. F. (2025). Rehabilitation Protocols and Functional Outcomes in Oncological Patients Treated with Modular Megaprosthesis: A Systematic Review. Cancers, 17(18), 2951. https://doi.org/10.3390/cancers17182951