Rehabilitation Treatment of a Patient With Total Humeral Endoprosthetic Replacement

Abstract

Total humeral endoprosthetic replacement (THR) is a rare surgery for malignant humeral bone tumors. Studies focusing on its surgical methods and functional status are limited. Furthermore, rehabilitation treatment after THR has not been reported. Therefore, this case report aimed to investigate its postoperative rehabilitation treatment and reinstatement. A 69-year-old woman was diagnosed with chondrosarcoma of her left humerus. THR was performed the day following patient admission. The wide resection caused the loss of her left shoulder motor function. She had a left ulnar nerve disorder and carpal tunnel syndrome. Rehabilitation treatments such as joint range of motion training were initiated on postoperative day (POD) 1. We designed a shoulder abductor brace to maintain her left shoulder in an abducted and flexed position so she could use her left hand effectively. The manual muscle testing scores for elbow joint movements gradually improved. On POD47, she was transferred to a convalescent rehabilitation hospital to receive training in activities of daily living and barber work. The patient was discharged on POD107. The Disabilities of the Arm, Shoulder, and Hand score improved from 86.2 (POD7) to 17.2 (POD107). She continued outpatient rehabilitation and reinstated work on POD143. The use of a brace and seamless rehabilitation from the acute phase to convalescence and community-based rehabilitation enabled the patient with THR to return to work. This study suggests that precise assessment of the disorders and consecutive rehabilitation treatment with a brace should be considered after THR.

Keywords: abduction brace; articular range of motion; chondrosarcoma; rehabilitation treatment; return to work; total humeral endoprosthetic replacement.

Figure 1. MRI and X-ray images of the left humerus

STIR (a), T1-weighted (b), and T1-weighted contrast-enhanced (c) images before surgery and X-ray images before (d) and after surgery (e) are shown. MRI, magnetic resonance imaging; STIR, short τ inversion recovery Arrows indicate the tumor observed from the head of the humerus to the distal four-fifths of the diaphysis.

Figure 2. Fixing method for the left shoulder

a: Chest band and arm sling. b: Shoulder brace without abduction pillow. c: Side view of the shoulder abduction brace. d: Front view. e: Back view. Arrows indicate abduction pillow.

Figure 3. Rehabilitation treatments by OT for returning to barber work and housework

a: Washing hair. b: Shaving. c: Hanging laundry. d: Knife handling. OT, occupational therapy Arrow: Additional white cushion to increase the shoulder abduction angle from 30° to 40°.

Figure 4. The course of rehabilitation treatment

The rehabilitation programs are described in the upper section. Time courses of the left grip (bar) and the MMT of the elbow and forearm (lines) are shown in the middle. FIM (bar), DASH (line with circles), and MSTS-UE (line with diamonds) are shown in the lower part. PT, physical therapy; OT, occupational therapy; MMT, manual muscle testing; FIM, functional independence measure; MSTS-UE, Musculoskeletal Tumor Society scoring system for the affected upper extremities; DASH, disabilities of the arm, shoulder, and hand; ROM, range of motion exercise; MSE, muscle strengthening exercise

Figure 5. Proposal for effective rehabilitation treatment for THR

Representative items of rehabilitation diagnosis and treatment are presented. Convalescent-phase rehabilitation and work training are unnecessary if the patient does not hope to work. Evaluation of the unaffected limb is also crucial because of its increased burden. ROM, range of motion; MSE, muscle strengthening exercise; ECG, electrocardiogram; MRI, magnetic resonance imaging; CT, computed tomography; PT, physical therapy; OT, occupational therapy; ADLs, activities of daily living; IADLs, instrumental activities of daily living