Tumour & limb salvage: rehabilitation guide
Last reviewed 5 August 2026 · Reviewed by Dr Matthew Broadhead, FRACS (Orth) · 25 minute read
This guide covers recovery after a proximal tibial replacement: a megaprosthesis that replaces the upper part of the shin bone and the knee joint, using a rotating-hinge knee, after a bone or soft-tissue tumour is removed. It is written for patients of the RPA Bone & Soft Tissue Sarcoma Unit and for the physiotherapists, often on the Mid North Coast, a long way from Sydney, who will deliver most of the programme.
One rule sits above everything else in limb-salvage rehabilitation: the site of the reconstruction, not the diagnosis, determines the protocol. Nowhere does that matter more than here. A distal femoral replacement: the other “knee megaprosthesis”, moves early; this operation is the opposite, because the patellar ligament (the tendon that lets you straighten the knee) has to be detached and reattached, usually reinforced with a muscle flap from the calf. Protecting that reattachment is the entire logic of this protocol, and Dr Broadhead’s operation record always overrides the general figures in this guide.
The core message of this guide is non-negotiable: the knee is held straight in a splint or brace for about six weeks, and it is not bent, not by you, not by a helpful relative, not by a physiotherapist who is used to standard knee replacements, until your team starts staged bending. Early bending does not loosen a stiff knee; it compromises the patellar ligament reattachment, and a repair that stretches or fails cannot be fully rebuilt. The stiffness you accept for six weeks buys you a knee you can straighten and stand on for life. That is the trade, and it is worth it.
A megaprosthesis replaces a segment of bone and the adjacent joint. The metal is fixed and stable straight away; what dictates your programme is which muscles and tendons had to be detached and reattached. Recovery is measured in months, not weeks, and the functional ceiling is lower than after a standard knee replacement: most patients walk independently, with or without a stick, and return to daily activities, but not to running or impact sport. Early, staged, active rehabilitation is safe, reviews of limb-salvage rehabilitation show early active mobilisation does not increase dislocation or infection and is associated with better quality of life, and this protocol is exactly that: active from day one (isometrics begin immediately, walking begins early), just not bending. Lifelong: avoid impact loading to limit wear; expect that revision surgery is likely at some point over a lifetime; and keep lifelong vigilance for infection, deep infection is the most significant risk in this surgery, considerably more common than after standard joint replacement, and this site carries the highest infection risk of the megaprosthesis family because the bone sits directly under thin skin. Surveillance imaging of both the tumour site and the prosthesis continues for years.
The tumour was removed together with the segment of shin bone (tibia) it involved, including the knee end of the bone, with a margin of healthy tissue around it. The reconstruction is designed around what that removal required.
The missing bone and joint were replaced with a modular metal implant anchored in the remaining tibia, connected to a component in the thigh bone through a rotating-hinge knee. The hinge provides the stability the resected ligaments can no longer supply.
The step that defines your rehabilitation: the patellar ligament: the tendon connecting your kneecap to the shin, through which every ounce of knee-straightening force passes, attaches exactly where the tumour was removed. It was detached and reattached to the prosthesis, and the repair is usually reinforced and covered with a gastrocnemius flap: a muscle moved up from your calf, which also gives the implant healthy soft-tissue cover under the thin skin of the shin. That tendon-to-metal repair heals slowly, on a biological timetable, and it cannot be protected by the hinge or the stem. Only stillness protects it, which is why this protocol is the strictest in the library.
Limb-salvage programmes are built around what was removed and reattached, not around the name of the tumour. This site demands the strictest protocol of the megaprosthesis family because the patellar ligament reattachment is unprotectable by anything except immobilisation. Your operation record is the final word, if anything here conflicts with your team’s instructions, your team is right. Physiotherapists: this is not a standard knee replacement, and standard early-flexion protocols actively harm this repair.
The knee stays in full extension in its splint or brace for about six weeks. No bending, active or passive. This is not caution for its own sake: early mobilisation compromises the patellar ligament reattachment, and a stretched repair means a permanent lag: a knee that cannot actively straighten, ever. The stiffness you accept for six weeks buys you a knee you can straighten and stand on for life.
Isometric (muscle-tightening) exercises begin immediately: quadriceps, gluteals, calf: inside the brace, from day one. You will also be up and walking early, taking partial weight through the braced, straight leg. The muscles are kept alive while the tendon heals; what is forbidden is movement at the knee, not effort.
After about six weeks, your team starts flexion deliberately: roughly 30-degree increments every two weeks, under physiotherapy supervision, with the brace advanced at each step. It feels slow because it is meant to be: each increment loads the repair a little more, and the repair sets the pace. Do not let anyone “push through” it.
If the repair stretches, the kneecap rides upward: patella alta, and the straightening mechanism loses its leverage. This develops in a majority of patients to some degree even with good care, and it matters: in endoprosthetic series, patients who develop patella alta average an extension lag of about 17 degrees, versus about 4 degrees in those who do not. That difference: a knee that hangs bent versus one that holds straight, is what the six braced weeks are protecting.
Your team may mention two scores. The MSTS score is the clinician’s rating of limb function from 0 to 100%. The TESS is your own rating of how difficult everyday tasks are. Good limb-salvage results typically land in the 70–85% range on these scales: good function, not normal function. A score in that range is a genuinely good outcome after this surgery.
Weight bearing
Partial weight bearing in the locked brace during the ~6 weeks of immobilisation, then full weight bearing once the immobilisation period ends. The operation record governs.
The implant itself is stable immediately, and with the brace holding the knee straight, weight passes through the limb without pulling on the tendon repair, which is why walking is allowed while bending is not.
During the braced weeks you take partial weight through the operated leg with a frame or crutches, exactly as your team prescribes. After the immobilisation period ends, you progress to full weight bearing.
Walking aids stay longer than weight bearing rules do: even at full weight, the crutches and later the stick come off as bending, strength and gait control return over the following months: your physiotherapist paces this.
| Stage | Typical timing | Move on when |
|---|---|---|
| Wheeled frame, brace locked straight | From day 1 through the early braced weeks | Safe transfers; partial weight bearing maintained; brace worn correctly |
| Two crutches, brace locked straight | During the braced weeks, as confidence allows | Steady, safe gait at the prescribed weight bearing |
| Two crutches, full weight bearing | After the ~6-week immobilisation ends | Team confirms the repair is ready; flexion programme starting |
| One crutch, then a stick | Over the following months, as bending and quadriceps control return | Knee trustworthy; no giving way; gait your physiotherapist is happy with |
Every ounce of knee-straightening force passes through the reattached patellar ligament, and for the first weeks that repair is held by stitches and healing tissue, not by strength. Bending the knee tensions it directly. A repair that stretches produces patella alta and a permanent extension lag; a repair that fails cannot be fully rebuilt. Nothing about a stiff knee at six weeks is dangerous; everything about a bent one is.
| Rule | Why | How to manage |
|---|---|---|
| The knee stays in full extension in its splint or brace, about 6 weeks, full time | Only stillness protects the tendon-to-prosthesis repair. The hinge and the stem cannot. | Brace on for walking, resting and sleeping, and removed only as your team explicitly directs (for example, for supervised wound checks and washing with the leg held straight). |
| No bending of the knee: active or passive, until your team starts it | Early mobilisation compromises the reattachment. It does not matter whether you bend it or someone bends it for you; the repair feels only the tension. | Tell family, carers and any treating clinician who is new to your case. If a well-meaning professional proposes “gentle early range of movement”, decline and have them call the rooms. |
| Partial weight bearing only, until the immobilisation period ends | The braced, straight leg can take partial load safely; full loading waits until the repair has had its six weeks. | Use the frame or crutches exactly as prescribed; your physiotherapist will teach you what your prescribed weight feels like. |
| Isometric exercises are compulsory, not optional | Six still weeks would otherwise waste the quadriceps: the muscle the whole reconstruction exists to serve. Isometrics keep it alive without moving the knee. | Quadriceps, gluteal and calf isometrics from day one, on the schedule in the exercise section. |
| After 6 weeks: bending advances in roughly 30° increments every 2 weeks, under physiotherapy supervision | Each increment loads the repair a little more; the staging lets it adapt without stretching. | The brace dial is advanced by your team at each step. Never advance it yourself, and never let a session “push on” past the current limit. |
| Period | Instruction |
|---|---|
| Weeks 0–6 (approximately: the operation record governs) | Full time: walking, resting and sleeping. Removed only as your team explicitly directs, with the knee held straight throughout. |
| From about week 6 | Converted to a hinged brace for the staged bending programme; worn as your team directs while the permitted range advances. |
| Weaning | Your team weans the brace once bending and quadriceps control are established: a review decision, not a calendar date. |
| Period | Permitted range |
|---|---|
| Weeks 0–6 (approx.) | Locked in full extension: 0 degrees. No bending, active or passive. |
| Weeks 6–8 (approx.) | About 0–30 degrees, started and supervised by your physiotherapist |
| Weeks 8–10 (approx.) | About 0–60 degrees, advanced by your team |
| Weeks 10–12 (approx.) | About 0–90 degrees, advanced by your team |
| Beyond 12 weeks | Advanced further as your team directs, guided by the repair, final bend is usually somewhat less than a native knee |
| Milestone | Earliest (weeks) | Typical | Latest |
|---|---|---|---|
| Standing and walking with a frame, brace locked, partial weight | 0 | 1 | 2 |
| Wound and flap review | 2 | 2 | 3 |
| Two crutches, brace locked | 2 | 3 | 6 |
| Clinical review with X-ray: immobilisation ends, flexion starts | 6 | 7 | 8 |
| Full weight bearing | 6 | 6 | 8 |
| Permitted bend about 0–30° | 6 | 7 | 9 |
| Permitted bend about 0–60° | 8 | 9 | 11 |
| Permitted bend about 0–90° | 10 | 11 | 14 |
| Desk work (individually confirmed, earlier if the leg can be kept elevated and straight) | 6 | 8 | 12 |
| Brace weaned (team decision) | 10 | 12 | 16 |
| One crutch or a stick | 10 | 14 | 20 |
| Driving (criteria met, discussed with the team) | 10 | 14 | 20 |
| Three-month review | 12 | 13 | 14 |
| Surveillance imaging: schedule set by the sarcoma team, continuing for years | 12 | 13 | 52 |
You move to the next phase by meeting its exit criteria, not by the calendar. The week numbers are typical, nothing more.
Brace locked in full extension, isometrics from day one, partial-weight walking with the frame, swelling controlled.
Ready for the next phase when…
Hold the line: brace locked, isometrics daily, walking tolerance building on crutches: patience as an active skill.
Ready for the next phase when…
Staged flexion in roughly 30° increments every 2 weeks under physiotherapy supervision, full weight bearing, and the quadriceps put to work through range.
Ready for the next phase when…
Strength, endurance and confidence for real life; the brace weaned; honest expectations about the final bend; the lifelong routine of surveillance.
Ready for the next phase when…
Little and often beats one heroic session. Each exercise lists what you should feel, sharp pain that lingers afterwards means ease off and, if it persists, call.
Keep blood moving in the calf: your main clot-prevention exercise, and doubly important with the leg immobilised.
10 firm pumps, every waking hour, for the first 2 weeks and throughout the braced period
Feel: You should feel the calf muscles working. The brace does not restrict the ankle, use the full range every time.
The backbone of the braced weeks: keep the thigh muscle alive while the tendon heals. Isometric work tightens the muscle without moving the knee, which is exactly why it is safe from day one.
10 holds of 5 seconds, every waking hour in the first weeks, then at least 3–4 times daily throughout the braced period
Feel: You should feel the thigh firm up under your hand, put a hand on it to check. No movement at the knee is the whole point: tension without motion.
Keep the hip and buttock muscles working while the leg is immobilised.
10 holds of 5 seconds, 3–4 times daily
Feel: You should feel the buttocks tighten and rise slightly. Keep breathing: do not hold your breath.
Whole-leg strength with the knee held safely straight by the brace: the braced weeks’ one “moving” leg exercise.
10 lifts, hold 3 seconds, 3 times daily, once your physiotherapist starts it
Feel: The locked brace keeps the repair safe while the hip and thigh do the work. If the leg is too heavy at first, keep working the static sets. The lift will come.
Early, safe walking: the leg straight and braced, the load partial, the habit priceless.
Short walks, several times a day, at exactly the prescribed weight bearing
Feel: The braced leg swings from the hip: let it. Rhythm beats distance in these weeks.
A smoother, more upright walk as confidence builds, still partial weight and locked brace until the team says otherwise.
Replace frame walks once your team progresses you; build distance week on week
Feel: Stand tall; look ahead, not at your feet. Same prescribed weight through the operated leg: crutches change the tool, not the rules.
Safe, repeatable stair climbing with a braced straight leg.
Practise with your physiotherapist first, then as needed
Feel: “Good leg up first.” The braced leg comes up straight and trailing: give it room.
The higher-risk direction: controlled descent protects the repair and your confidence.
Practise with your physiotherapist first, then as needed
Feel: “Braced leg and crutches down first.” If in doubt, go down sitting: dignity heals faster than a fall.
Soften and desensitise the scar once fully healed, with your team’s specific go-ahead over the flap.
2–3 minutes, twice daily, from about 3 weeks once healed, dry, and cleared by your team
Feel: Firm enough to blanch the skin slightly; it should not be painful. If you have had radiotherapy to the area, ask your team before starting.
Earn the bend back in stages, roughly 30° more every two weeks, without stretching the repair that six braced weeks just protected.
Supervised sessions as scheduled by your physiotherapist; between sessions, 10 slow bends to the current permitted limit, 3 times daily
Feel: The dial belongs to your team: the increments advance at reviews, on the plan, roughly every two weeks. Finish every session with the knee actively held straight: the bend must never cost the straightening.
Loaded straightening in the most useful movement you own: introduced once bending and full weight bearing allow.
2–3 sets of 8–10, once or twice daily, once your physiotherapist starts it
Feel: The slow lowering is where the quadriceps learns the most. Raise the seat if the knee has to bend past its permitted range to sit.
Harder: Less arm assistance, then a lower seat: as your permitted range and your physiotherapist allow.
Rebuild the calf, which matters double here, because the gastrocnemius flap borrowed part of it.
2–3 sets of 10, once or twice daily, once your team clears calf loading
Feel: Expect the operated side to feel weaker. The flap changed the calf’s anatomy, and some difference may persist. Even, unhurried repetitions.
Range, circulation and endurance with almost no load on the repair, once the bend allows it.
10–20 minutes, most days, once your permitted bend allows a full revolution and your team agrees
Feel: Stay inside the permitted range: the saddle height is how you control it.
Steadiness and confidence: protects you from trips and falls.
Build to 3 holds of 30 seconds each leg, daily, once your team clears single-leg loading
Feel: Quiet foot, tall posture. This is where six weeks of isometrics pay their dividend.
The brace stays on in bed throughout the immobilisation period, sleep is a third of the six weeks, and an unbraced bend in your sleep is exactly what the brace exists to prevent.
Sleep on your back with the braced leg supported along its whole length. A pillow under the calf and heel keeps it comfortable, never a pillow under the knee.
If you are more comfortable slightly turned, keep the braced leg straight and supported and put the pillow between the legs.
Disturbed sleep is common for some weeks. The brace is a poor bedfellow, and that is normal. Timing pain relief for the night, and icing before bed, both help. It gets easier when the hinged phase begins.
Expect to need regular pain relief for the first few weeks, weaning gradually. Take medication ahead of exercise and walking sessions rather than chasing pain afterwards, and wean the strongest medications first.
You will usually be on a blood thinner, take it exactly as directed; it matters even more with the leg immobilised.
The calf donor site for the flap has its own ache in the early weeks, expected, and it settles.
If you are having chemotherapy, the rehabilitation and oncology timetables are coordinated by your team, energy levels, blood counts and treatment cycles all shape what each week looks like, and a slower fortnight during treatment is expected, not a setback.
When staged bending starts after week six, expect a firm stretching discomfort with each new increment. That is normal. Sharp pain at the front of the knee that lingers after a session is not: stop at the current stage and call.
Pain that is increasing week on week, or new pain at rest or at night, is never “just stiffness”, call the rooms.
You may drive when all of the following are true:
What the research actually measures is braking reaction time on a simulator. Those studies show braking performance returns to its pre-operative level at about 2 weeks after a right hip replacement and about 4 weeks after a right knee replacement, with movement time back to normal by 6 weeks. After knee arthroscopy the simulator evidence is more conservative than common practice: in the one study that measured it directly, braking was still slower one week after surgery than before it, and had recovered by four weeks, and a 2021 review of eight studies put the average return at about six weeks. Most people having a simple arthroscopy are driving well before that, which is why the criteria above matter more than the date. But these are averages, in one study, about one in three right-hip patients still could not meet an emergency-stop benchmark at six weeks. Treat the timeframes in this guide as targets for discussion with us, not as permissions.
No published study has compared automatic and manual cars. The logical point is simply that a manual needs the left leg for the clutch, so left-sided surgery is the relevant caution in a manual. Advice about driving earlier with a left-leg operation in an automatic is clinical judgement, not trial evidence.
In Australia, your treating doctor’s advice governs: under the Austroads "Assessing Fitness to Drive" standards, temporary post-operative impairment is a matter of clinical judgement, and commercial drivers are held to a higher standard. Driving while impaired may invalidate your insurance, check your insurer’s position. Do not drive for at least 24 hours after any general anaesthetic or sedation.
| Activity | Typical | When it’s right | Notes |
|---|---|---|---|
| Walking for exercise | From the outset: braced, partial weight, with the frame or crutches | Prescribed weight bearing and brace rules followed | Distance builds properly once immobilisation ends |
| Swimming and hydrotherapy | After the immobilisation period, once the wound and flap are fully healed and your team agrees | Wound and flap reviewed and closed; bending sufficient for safe pool entry | Excellent low-load exercise once cleared |
| Stationary cycling | Once the permitted bend allows a revolution, usually some weeks into the flexion programme | Team-set range sufficient; saddle high | Progress time before resistance |
| Driving | Not while braced; individually assessed after bending and control return | All the driving criteria below, discussed with the team, including being out of any brace that limits the movements needed for the pedals | For a right leg this is usually well after the 6-week point; plan on being a passenger for a while |
| Desk work | Commonly in the 6–12 week window, earlier is possible if the leg can be kept elevated and straight | Comfortable positioning; transport sorted | The straight-leg sitting set-up from the precautions section applies at the desk too |
| Physical work | Individually assessed | Duties reviewed with the team | Heavy physical work is often not a realistic goal after proximal tibial replacement, raise your actual duties early so modified duties or retraining can be planned honestly |
| Golf, bowls, doubles tennis and similar low-impact sport | Team-cleared, usually well after 3 months | Strength, balance and a trustworthy knee | Discuss the specific sport: rotation, uneven ground, and anything that risks a blow to the shin are the considerations |
| Kneeling | Only after specific discussion with your team | Skin and flap robust; team agreement | Direct pressure over the thin skin at the front of this implant is a lifelong caution, not just an early one |
| Running, jumping and impact or contact sport | Not part of life with a megaprosthesis | — | This is a permanent trade: impact accelerates wear, endangers the repair, and risks fracture through bone weakened by resection, radiotherapy and chemotherapy |
| Air travel | Discuss with the team: see the travel notes in this guide | Clot prevention planned; a braced straight leg needs a bulkhead or aisle plan | Especially relevant for Mid North Coast patients travelling to Sydney for reviews. The same planning applies to long drives: break them up, move hourly |
You will often hear "no flying for six weeks" after joint replacement. Be aware that this is a convention, not a proven rule: a 2025 review found limited data and no demonstrated difference in clot risk between people who did and did not fly after hip or knee replacement: mostly within the first week.
The six-week convention reflects practical realities rather than trial evidence: managing airports and cramped seating, being past the highest-risk clot window while still on prevention, the higher baseline clot risk of long-haul flights over four hours, and individual airline and travel-insurance rules, check both, as some airlines impose their own restrictions.
If you need to travel long-haul in the first six weeks, talk to the rooms first so clot prevention, an aisle seat, stockings and on-board movement can be planned.
None of these should be watched overnight to see how they go. Early treatment of a problem is simple; late treatment is not.
EMERGENCY: 000Emergency department / call 000
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CALL THE ROOMSCall the rooms: same day
For joint replacement patients, a wound problem is never something to "wait and see". Early treatment of an infected joint replacement is vastly more successful than late treatment, call the rooms the same day.
Sooner than most people expect: you will usually be up walking with a frame within a day or two of surgery: the brace holds the knee straight, and weight passes through the limb without pulling on the tendon repair. You walk with partial weight through the braced weeks, progress to full weight after the immobilisation ends at about six weeks, and then wean from crutches to a stick over the following months. Recovery is measured in months, not weeks, and many people keep a stick for distance long term, which is a sensible adaptation, not a setback.
Because this is not that operation: the site of the reconstruction, not the diagnosis, determines the protocol. In a standard knee replacement the tendon that straightens your knee is left attached. Here it had to be detached and reattached to the prosthesis, and for about six weeks that repair is held by stitches and healing tissue, not strength. Bending the knee: actively or passively: tensions it directly, and early mobilisation compromises the reattachment. A stretched repair means a kneecap that rides high and a knee that can never again fully straighten on its own. The stiffness you accept for six weeks buys you a knee you can straighten and stand on for life.
The knee is held in full extension in its splint or brace for about six weeks, full time: walking, resting and sleeping. After that, your team converts it to a hinged brace and starts flexion deliberately: roughly 30 degrees more every two weeks, under physiotherapy supervision, about 0–30°, then 0–60°, then 0–90°, with the dial advanced at each review, never by you. The brace is weaned once bending and muscle control are established, as a review decision rather than a date.
This is the fear behind most protocol violations, so here is the honest answer: temporary stiffness after immobilisation recovers with the staged programme. That is what phases 3 and 4 are for, and final bend usually ends up somewhat less than a native knee, mostly because of the surgery itself rather than the bracing. What does not recover is a stretched or failed tendon repair. Between a knee that is temporarily stiff and a knee that permanently cannot hold itself straight, the six braced weeks choose the right problem.
If the reattached tendon stretches, the kneecap rides upward: patella alta, and the straightening mechanism loses its leverage. Some upward drift develops in a majority of patients even with good care, which is exactly why the protocol is so strict about not adding to it. It matters because of the lag: in endoprosthetic series, patients who develop patella alta average an extension lag of about 17 degrees: the knee hangs bent when they try to hold it straight, versus about 4 degrees in those who do not. Those six braced weeks are the price of being in the second group.
No, and it is better to hear that clearly at the start. Running, jumping and impact sport are not part of life with a megaprosthesis: impact accelerates wear, endangers the tendon repair, and risks fracture through bone weakened by the resection and by any radiotherapy or chemotherapy. The realistic and genuinely good outcome is independent walking, with or without a stick, a full daily life, and low-impact exercise such as walking, swimming and cycling.
The repair is usually reinforced and covered with a gastrocnemius flap: part of your calf muscle, moved up to wrap the reattachment and give the implant healthy soft-tissue cover under the thin skin of the shin. The donor area on the calf has its own ache and its own scar, both of which settle, though the calf may stay a little weaker. The flap is one more reason the early weeks are handled so carefully, and why the skin over the front of your shin deserves lifelong respect: report any blister, graze or colour change over the implant the same day.
Deep infection is the most significant risk of this surgery, considerably more common than after standard joint replacement, and the proximal tibia is the highest-risk site of all because the implant sits directly under thin skin. Watch for increasing pain, spreading redness, wound discharge, fever, feeling unwell, or any skin problem over the shin, and call the rooms the same day, every time, for the rest of your life with the implant. Early treatment of an infected prosthesis is vastly more successful than late treatment. Tell every future dentist and doctor you have a megaprosthesis before procedures.
Two ways of measuring how the limb is doing. The MSTS score is the clinician’s rating of limb function on a 0–100% scale; the TESS is your own rating of how difficult everyday tasks are. Good limb-salvage results typically land in the 70–85% range. That means good function, not normal function, and a score in that range after a proximal tibial replacement is a genuinely good outcome.
This is normal and it works well, with one crucial caveat for this particular operation: the protocol is unusual, and a physiotherapist meeting it for the first time should know that standard knee replacement rehabilitation actively harms this repair. Most of the hands-on work happens locally, guided by the operation record and the written protocol from your Sydney team; the staged flexion increments are set at your reviews and communicated in writing, and your physiotherapist is welcome, encouraged, to call the rooms directly before changing anything. Bring this guide and your operation record to your first local appointment.
The general convention after joint replacement is no long-haul flying for 6 weeks, though the evidence behind a fixed rule is limited, and a leg braced straight adds a practical seating problem, so talk to the team before booking anything early. For the drive from the Mid North Coast: travel as a passenger with the seat back and the braced leg supported, break the trip every hour to move and do your ankle pumps, and elevate the leg at the destination. Driving yourself waits until the brace is off for driving movements and the criteria in this guide are met.
Plan on it, calmly: over a lifetime, revision surgery of some kind is likely, components wear, and the implant is serviced rather than permanent. This is one reason for the permanent no-impact rule and for the surveillance imaging of both the tumour site and the prosthesis, which continues for years: problems found early are far easier to fix. Between scans, report anything new: a lump, new pain anywhere, a skin concern over the shin: the same day you notice it.
| Claim | Source |
|---|---|
| The site of reconstruction, not the diagnosis, determines the rehabilitation protocol; proximal tibial replacement follows the most restrictive protocol of the lower-limb megaprostheses | Standardisation of rehabilitation after limb salvage surgery for sarcomas, Hematol Oncol Stem Cell Ther 2013 (PMID 24161605); functional outcomes of endoprosthetic reconstruction by site, Clin Orthop Relat Res 2015 (PMID 24777730) |
| Early, staged, active rehabilitation after limb-salvage surgery is safe, no increase in dislocation or infection, associated with better quality of life | Standardisation of rehabilitation after limb salvage surgery for sarcomas improves outcome, Hematol Oncol Stem Cell Ther 2013 (PMID 24161605); occupational therapy rehabilitation after limb salvage surgery, a scoping review, Disabil Rehabil 2021 (PMID 31180732) |
| Immobilisation of the knee in extension for about 6 weeks after patellar ligament reattachment, with isometric exercise from the outset and staged flexion thereafter, is the standard protective protocol; early mobilisation compromises the reattachment | Muscle function after endoprosthetic replacement of the proximal tibia, comparing techniques for extensor reconstruction, Acta Orthop Scand 1995 (PMID 7604712); extensor function after medial gastrocnemius flap reconstruction, Clin Orthop Relat Res 2013 (PMID 23423620) |
| Flexion after proximal tibial replacement is reintroduced in staged increments (of the order of 30° every 2 weeks) under supervision | Muscle function after endoprosthetic replacement of the proximal tibia, comparing extensor reconstruction techniques, Acta Orthop Scand 1995 (PMID 7604712). The staged increments themselves are unit protocol rather than a trial finding |
| Patella alta develops in a majority of patients after proximal tibial replacement with extensor mechanism reattachment; patients who develop it average an extension lag of about 17° versus about 4° in those who do not | Extensor function after medial gastrocnemius flap reconstruction of the proximal tibia, Clin Orthop Relat Res 2013 (PMID 23423620). Patella alta developed over the first 2 postoperative years and then stabilised; it carried a larger extensor lag (mean 17° against 4°) but more flexion (94° against 77°) |
| Medial gastrocnemius flap coverage of the proximal tibial implant and extensor mechanism repair improves soft-tissue cover and reduces wound complications | Extensor function after medial gastrocnemius flap reconstruction of the proximal tibia, Clin Orthop Relat Res 2013 (PMID 23423620); medial gastrocnemius flap in limb-sparing surgery for proximal tibial tumours, Ann Plast Surg 2003 (PMID 12966238) |
| Deep infection is the most significant complication of megaprosthetic reconstruction, considerably more common than after conventional arthroplasty, and the proximal tibia is the highest-risk anatomical site | Henderson et al., failure mode classification for tumour endoprostheses, J Bone Joint Surg Am 2011 (PMID 21368074); the fate of periprosthetic joint infection following megaprosthesis reconstruction, JB JS Open Access 2021 (PMID 34841189); complications after proximal tibial reconstruction, PLoS One 2015 (PMID 26270336), where 56% of patients had at least one complication |
| Revision surgery is likely at some point over a lifetime with a megaprosthesis; impact loading accelerates wear and is advised against | Survival of megaprostheses in lower limb reconstruction after tumour resection, Clin Orthop Relat Res 2015 (PMID 24964884); complications after proximal tibial reconstruction, PLoS One 2015 (PMID 26270336) |
| MSTS is a clinician-rated 0–100% limb-function score; TESS is a patient-reported measure of everyday task difficulty; good limb-salvage outcomes typically fall in the 70–85% range | Enneking et al., MSTS functional evaluation system, Clin Orthop Relat Res 1993 (PMID 8425352); Davis et al., development of the Toronto Extremity Salvage Score, Qual Life Res 1996 (PMID 8973131); functional outcomes of endoprosthetic reconstruction after tumour resection, Clin Orthop Relat Res 2015 (PMID 24777730) |
| Bone weakened by resection, radiotherapy and chemotherapy carries an elevated periprosthetic fracture risk, including after minor loading | Henderson et al., failure mode classification for tumour endoprostheses, J Bone Joint Surg Am 2011 (PMID 21368074), in which periprosthetic fracture is a recognised failure mode; late complications and survival of endoprosthetic reconstruction, Clin Orthop Relat Res 2010 (PMID 20625951). The added contribution of radiotherapy and chemotherapy to that risk is a clinical concern rather than a quantified finding |
| Long-term surveillance imaging of the tumour site and prosthesis is standard of care for years after sarcoma resection and endoprosthetic reconstruction | Soft tissue and visceral sarcomas: ESMO-EURACAN-GENTURIS clinical practice guidelines, Ann Oncol 2021 (PMID 34303806) |
This guide is general information for patients of Dr Matthew Broadhead (Harbour Orthopaedics & Sports Medicine) and is not a substitute for the specific advice given to you by Dr Broadhead, your physiotherapist or your hospital team.
Surgical findings vary, and your protocol may differ from what is written here: your operation record and your surgeon’s instructions always take precedence.
If in doubt, call the rooms on (02) 9052 1883. In an emergency, call 000.
Last reviewed: 2026-08-05 by Dr Matthew Broadhead, FRACS (Orth).
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