Background: The treatment of a malignant bone tumor in the distal aspect of the femur often requires great sacrifice of bone and muscle. The extent of quadriceps removal has been reported to influence the long-term functional efficiency of a patient's gait. The objective of the present study was to determine gait function as it relates to the residual quadriceps strength and to the specific component or components of the quadriceps removed in patients treated with total knee replacement because of a malignant bone tumor in the distal aspect of the femur.
Methods: Sixteen patients were evaluated after implantation of a modular hinged cementless knee prosthesis. The patients were assigned to two groups on the basis of the different components of the quadriceps muscle that were resected. Group 1 consisted of five patients who had removal of the vastus medialis and the vastus intermedius and two who had removal of the vastus medialis only. Group 2 consisted of nine patients who had removal of the vastus lateralis and the vastus intermedius. Residual muscular strength about the treated knee was measured by voluntary maximum contraction isometric testing. Foot-ground reaction forces, kinematic and kinetic findings, and electromyographic activity during free-speed walking were recorded.
Results: The kinematic study showed that the patients in Group 1 tended to have a stiff-knee gait during stance, whereas those in Group 2 (in which the vastus medialis was spared) had a more regular flexion-extension knee pattern. Electromyographic findings showed that a higher percentage of patients in Group 1 had reduced or absent rectus femoris activity during the loading response. Compared with the contralateral side, knee-extension strength in the treated limb was decreased in both groups. However, there were no significant differences between the groups with respect to the pattern of strength loss.
Conclusions: Good gait function can be achieved in patients with a distal femoral tumor that is treated with distal femoral resection, partial excision of the quadriceps, and total knee arthroplasty with insertion of a hinged prosthesis. Patients in whom the vastus lateralis and vastus intermedius were removed had better gait performance and a more physiological knee-loading pattern than did patients in whom the vastus medialis was removed.