Intramedullary and total femur replacement in revision arthroplasty as a last limb-saving option

Total femur replacement in revision arthroplasty for non-oncologic patients: a systematic review

PURPOSE

Revision total joint arthroplasty cases including those complex enough to require limb-salvage procedures are expected to significantly increase. Total femoral replacements represent a limb-preserving procedure with potential utility for these complicated cases. This review seeks to summarize the outcomes of total femoral replacements when used in the revision arthroplasty setting.

METHODS

A systematic review was performed by searching Embase, Ovid MEDLINE, PubMed, Wiley Cochrane Library: Central Register of Controlled Trials, and Thompson Reuters Web of Science: Citation Index on February 8, 2024 for studies describing any outcomes and complications of total femur replacements performed for revision arthroplasty. Functional outcomes and postoperative complications were subsequently summarized. This study was registered with PROSPERO (CRD42024509031). Risk of bias assessment was performed using the Methodological Index for Nonrandomized Studies.

RESULTS

Eleven of 4817 initially screened studies were included. Indications for total femur replacement largely consisted of periprosthetic infection, periprosthetic fracture, hardware loosening, or a combination thereof. Articles described variable benefit in function, pain, and ambulatory ability. Patients had improved hip and knee function, reduced pain levels, and preserved independent ambulatory ability, though patients largely still required assistive devices. Benefits were limited by the high risk of postoperative complications, especially infection and dislocation.

CONCLUSION

Total femur replacement is an option for limb-salvage surgery in complex revision arthroplasty cases but has high complication rates, particularly infection and dislocation. Advancements aimed at minimizing these complication rates including silver- and iodine-coated implants will be critical in establishing the viability of total femur replacements in this setting.

Single-Institution Experience With Nononcologic Total Femoral Replacement

Background

Revision hip and knee arthroplasty volume continues to rise, and total femur replacement (TFR) remains a key salvage option in patients with extensive bone loss. Prior research has demonstrated mixed results of this procedure, and this study aimed to characterize the outcomes of nononcologic TFR in one of the largest single-center modern series.

Methods

A retrospective analysis was conducted on 23 nononcologic TFR procedures performed on 22 patients between 2012 and 2021. Primary outcomes included TFR revision rate and indication for revision, while secondary outcomes included overall reoperation rate, complications, patient ambulatory status, and assistive device requirements.

Results

The average age at time of TFR was 65.7 years, with periprosthetic fracture (65.2%) and periprosthetic joint infection (34.8%) as predominant indications. More than half of patients (52.2%) required TFR revision, primarily due to periprosthetic joint infection (75.0%). Despite a high complication profile, only 1 patient underwent limb amputation and there was only 1 mortality during the study period. Overall, 63.6% of patients were ambulating (assisted or unassisted) at final follow-up.

Conclusions

Nononcologic TFR remains a viable limb-salvage option for patients undergoing revision arthroplasty with extensive bone loss. Despite a notable revision rate and infection risk, the majority of patients maintain or regain ambulatory function, emphasizing the procedure's role in preserving limb function. Clinicians should weigh potential complications when considering TFR, emphasizing patient counseling and risk mitigation strategies.

Intramedullary Total Femur via a Direct Anterior Approach for Complex Revision Total Hip and Knee Arthroplasty

Total femur replacement is a well-recognized salvage procedure and an alternative to hip disarticulation in patients with massive femoral bone loss. Compared to conventional total femur replacement, intramedullary total femur (IMTF) requires less soft tissue dissection and preserves femoral bone stock and soft-tissue attachments. Despite these advantages, patients can still anticipate compromised functional outcomes and high complication rates following IMTF. Prior studies describe IMTF with the patient positioned laterally and utilizing posterior or anterolateral approaches to the hip. We describe our IMTF technique performed via the direct anterior approach in the supine position. In our experience, this is an effective method, with potential benefits including intraoperative limb length and rotational assessment, use of fluoroscopy, more convenient exposure of the knee, and potential lower rates of hip instability.

Comparative Outcomes and Failure Rates of Total Femur Replacement in Oncologic and Nononcologic Indications: A Systematic Review and Meta-analysis

BACKGROUND

Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication.

METHODS

This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models.

RESULTS

A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery.

CONCLUSION

TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Outcomes of Total Femur Replacement in Oncologic and Nononcologic Patients: A Systematic Review of the Literature

BACKGROUND

Total femur replacement (TFR) is used for primary reconstruction after extensive tumor resection or as a revision surgery due to prosthetic failure. Studies on TFR rates of failure and functional outcomes are scarce. The purpose of our study was to compare the modes of failure, amputation rates, and functional outcomes after TFR between oncologic and nononcologic patients.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were for this manuscript. Our study was registered on PROSPERO (413582). Quality assessment of all studies was performed using Strengthening the Reporting of Observational Studies in Epidemiology checklist. Endoprosthesis failure was assessed using the Henderson classification and functional outcomes using the Musculoskeletal Tumor Society score. Weighted means and standard deviations were calculated.

RESULTS

Overall failure rate was similar between groups. Henderson type 4 failures were more common within the nononcologic group, while the others were more frequently found in the oncologic group. Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Amputations occurred mainly after type 4 and type 5 failures. Functional outcome was better within the oncologic group (70.5 versus 61.7, respectively; P < .001).

CONCLUSIONS

Total femoral replacement in the oncologic and nononcologic group is associated with a high rate of failure (31% and 32.5%, respectively). Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Functional outcome was better within the oncologic group.

LEVEL OF EVIDENCE

Level III.

Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium

The evaluation, classification, and treatment of significant bone loss after total knee arthroplasty (TKA) continue to be a complex and debated topic in revision TKA (rTKA). Despite the introduction of new evidence and innovative technologies aimed at addressing the approach and care of severe bone loss in rTKA, there is no single document that systematically incorporates these newer surgical approaches. Therefore, a comprehensive review of the treatment of severe bone loss in rTKA is necessary. The Stavros Niarchos Foundation Complex Joint Reconstruction Center Hospital for Special Surgery, dedicated to clinical care and research primarily in revision hip and knee replacement, convened a Management of Bone Loss in Revision TKA symposium on June 24, 2022. At this meeting, the 42 international invited experts were divided into groups; each group was assigned to discuss questions related to 1 of the 4 topics: (1) assessing preoperative workup and imaging, anticipated bone loss, classification system, and implant surveillance; (2) achieving durable fixation in the setting of significant bone loss in revision TKA; (3) managing patellar bone loss and the extensor mechanism in cases of severe bone loss; and (4) considering the use of complex modular replacement systems: hinges, distal femoral, and proximal tibial replacements. Each group came to consensus, when possible, based on an extensive literature review and interactive discussion on their group topic. This document reviews each these 4 areas, the consensus of each group, and directions for future research.

Ipsilateral Hip and Knee Reconstruction Using an Intramedullary Total Femoral Replacement System

The intramedullary total femoral reconstruction (ITFR) was used successfully in a 62-year-old patient with myxoid liposarcoma of the thigh and post-radiation fracture nonunion of the proximal femur and osteonecrosis of the ipsilateral knee. This described technique offers the advantage of a less invasive prosthesis insertion, preservation of the surrounding muscle attachments, better functional outcomes, and lower complication rates. Total femoral reconstruction using ITFR, preserving the femoral diaphysis, could be an option to address concomitant hip and knee defects, especially in patients with poor soft tissue quality.

The Use of Megaprostheses in Nononcologic Lower-Extremity Total Joint Arthroplasty: A Critical Analysis Review

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As the number of primary total joint arthroplasty (TJA) procedures continues to rise, megaprostheses have found an emerging role in more complex revision arthroplasty cases that require additional reconstruction, stability, and restoration of function.

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Megaprosthesis options have evolved: in addition to cemented prostheses, cementless and even hybrid fixation designs optimize longevity. Proximal femoral replacement (PFR), distal femoral replacement (DFR), proximal tibial replacement (PTR), and total femoral replacement (TFR) are all limb salvage options in the setting of substantial bone loss, poor bone quality, and soft-tissue compromise.

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Dislocation is one of the most common complications after PFR, likely due to the loss of soft-tissue integrity, most notably the hip abductor musculature from the greater trochanter. The utilization of dual-mobility constructs, larger femoral heads, elevated acetabular liners, and constrained acetabular liners may reduce the risk of instability and improve overall hip function.

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Patients with megaprostheses may be more prone to periprosthetic joint infection and surgical site infection given multiple variables, such as the lengthy nature of the surgical procedure, prolonged wound exposure, extensive soft-tissue dissection and resection, poor soft-tissue coverage, and poorer host status.

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Despite advances in technology, complication and revision rates remain high after megaprosthesis reconstruction. Therefore, thorough attention to patient-specific factors must be considered for appropriate use of these constructs.

Megaprostheses in Nononcologic Hip and Knee Revision Arthroplasty

Megaprostheses as a means of limb salvage originated in orthopaedic oncology, and implant evolution was initially driven by developments within this field. Improvements in imaging modalities and in chemotherapeutics prolonged patient survival and promoted a transformation in the surgeon's mentality from salvage operation to functional limb reconstruction. As primary arthroplasty operations became more popular, megaprostheses found new utility in hip and knee revision arthroplasty. In this capacity, these implants provided much needed alternatives to traditional arthroplasty revision options for addressing massive bone loss and complex periprosthetic fractures. The indications for megaprostheses continue to expand with advances in design, stability, and overall longevity. Thus, greater numbers of orthopaedic surgeons in arthroplasty and traumatology have to be familiar with this technology. Importantly, each anatomic location presents unique considerations for reconstruction; however, additional variables such as the quantity of bone loss, the quality of remaining bone stock, and fracture type also influence implant selection. Ultimately, there is still much to be optimized in the use of megaprostheses for hip and knee revision arthroplasty. High multifactorial complication and revision surgery rates compared with conventional prostheses make these implants for many a "last resort" option.

Nonmechanical Revision Indications Portend Repeat Limb-Salvage Failure Following Total Femoral Replacement

BACKGROUND

There is scant evidence to guide decision-making for patients considering total femoral replacement (TFR). We aimed to identify the indication, patient, disease, and surgical technique-related factors associated with failure. We hypothesized that failure occurs more frequently in the setting of revision surgical procedures, with infection as the predominant failure mode.

METHODS

We performed a retrospective cohort study of patients receiving total femoral endoprostheses for oncological and revision arthroplasty indications; 166 patients met these criteria. Our primary independent variable of interest was TFR for a revision indication (arthroplasty or limb salvage); the primary outcome was failure. Analyses were performed for patient variables (age, sex, diagnosis group, indication), implant variables (model, decade, length, materials), and treatment variables. We analyzed TFR failures with respect to patient factors, operative technique, and time to failure. We conducted bivariate logistic regressions predicting failure and used a multivariate model containing variables showing bivariate associations with failure.

RESULTS

Forty-four patients (27%) had treatment failure. Failure occurred in 24 (23%) of 105 primary TFRs and in 20 (33%) of 61 revision TFRs; the difference was not significant (p = 0.134) in bivariate analysis but was significant (p = 0.044) in multivariate analysis. The mean age at the time of TFR was 37 years in the primary group and 51 years in the revision group (p = 0.0006). Of the patients who had mechanical failure, none had reoccurrence of their original failure mode, whereas all 8 patients from the nonmechanical cohort had reoccurrence of the original failure mode; this difference was significant (p = 0.0001).

CONCLUSIONS

TFR has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection. All failed TFRs performed for revision indications for infection or local recurrence failed by reoccurrence of the original failure mode and resulted in amputation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total femur prosthesis in oncological and not oncological series. Survival and failures

Total femur prosthesis (TFP) can be used in both oncological and prosthetic revision surgery. A retrospective analysis of 32 patients receiving a TFP at a single Center between 2002 and 2018 was performed. The average follow-up was 60 months. Revision implant free survival (RIFS) of the implants was 87% at 5 and 10 years and 72% at 15 years. Overall implant survival (OIS) of the prosthesis was 90% at 5, 10 and 15 years. Complications observed: two soft tissue failures, two infection failure and one tumor progression failure.

High complication and revision rates after total femoral replacement: a retrospective single center analysis of indication, function, and complication

INTRODUCTION

Total femoral replacement (TFR) is a limb salvage procedure performed for large bony defects. However, it is often associated with major complications and reduced function. Data on limb preservation rates and functional outcomes after TFR are limited. The primary objective of this study is to assess indications, functional outcomes, and complications after TFR.

MATERIALS AND METHODS

We retrospectively analyzed all patients after TFR between 2006 and 2016. All patients received a modular mega endoprosthesis (MUTARS^®). Patients were grouped according to their initial indication for TFR: (1) fracture, (2) tumor, or (3) infection. We evaluated (i) patient survival, (ii) postoperative function with the Musculoskeletal Tumor Society Score (MSTS), knee strength, range of motion, and (iii) complications.

RESULTS

Between 2006 and 2016, TFR was performed in 22 patients with a mean age of 64 +/-17 years. Indications for TFR were tumor (n = 6), infection (n = 8) and fracture (n = 8). The mean follow-up (f/up) was 18 months. At final follow-up, mean MSTS was 24%. Mean knee flexion strength was reduced 63% compared to the contralateral leg (p = 0.004). At time of final f/up, 5 patients (22%) died, 5 (22%) underwent secondary hip exarticulation, and 12 (54%) suffered a major complication. At f/up, 11 patients had infections. Of these 11 patients, 5 died, 4 were treated with debridement, and 5 were treated with hip exarticulation. Fifteen patients survived with preserved limbs at f/up.

CONCLUSION

TFR is a salvage procedure with limited functional outcome and high complication rates. Nevertheless, the majority of our cohort could be treated successfully with limb salvage.

Total femur replacement in non-oncologic indications: Functional and radiological outcomes from a French survey with a mean 6 years' follow-up

INTRODUCTION

There are few published studies on total femur replacement (TFR) because its indications are rare. Other than malignant diseases, the indications extend to revisions and interprosthetic femur fractures; however, the outcomes of these indications have not been well defined. The aim of this retrospective survey was to analyze the complication rate and functional outcomes of these newer indications.

HYPOTHESIS

The morbidity and outcomes after TFR are comparable to those reported in the literature for non-cancer indications.

MATERIAL AND METHODS

Between 1997 and 2016, 29 TFR procedures were done at 6 French teaching hospitals in 15 women and 14 men, average age 68±14 years [32-85]. The primary indication was degenerative joint disease in the hip and/or knee in 16 cases, mechanical failure of the implant used after tumor resection in 11 cases and femur fracture in 2 cases. The mean number of surgical procedures before TFR was 3.6 (maximum 5) at the hip and 4.5 (maximum 10) at the knee. Six different models were implanted consisting of a rotational hinge knee (except in one case); 20 patients received a dual mobility system and 9 a standard hip replacement bearing. The femoral shaft was partially conserved 21/29 times and the trochanter 25/29 times.

RESULTS

Five patients suffered a general complication and 12 suffered a local complication (including 4 hematomas and 2 hip dislocations). Eight patients (28.6%) suffered a surgical site infection, although three had a prior infection. Among the 12 patients with a history of infection or progressive infection before the TFR, 9 healed and 3 had the infection continue. At a minimum follow-up of 2 years and mean of 6 years, 23 TFR implants were still in place and not infected; the other 6 had been removed or were infected, including one patient who underwent disarticulation. The median survival of the non-infected TFR was 15 years. At 10 years, 70% of TFR implants were still in place and non-infected. Walking was possible with or without a cane in 15 patients (51.7%), with two canes or a walker in 12 patients (41.3%) and impossible in 2 patients. Active knee flexion averaged 79.4°±30.3° [0°-120°]; 17 patients (62.9%) had 90° or more flexion; two patients (7.4%) had no flexion. The extension deficit averaged 3.7°±7°[-20° to 10°] and 20 patients had no flexion deformity. The leg length difference averaged 1.3cm±2.3 [0-10]; 19 patients (67.8%) had no difference in leg length.

DISCUSSION

Our starting hypothesis was confirmed for the complication rate and clinical outcomes. The benefits of dual mobility cups are emphasized. While the indications for TFR are rare, they will likely increase in the coming years.

LEVEL OF EVIDENCE

IV, Retrospective cohort study….

A single centre study of 41 cases on the use of porous tantalum metal implants in acetabular revision surgery

Background

This study aims at investigating cup survival of porous tantalum revision cups and identifies risk factors for failure.

Methods

We retrospectively reviewed 41 patients treated between 2010 and 2012. Main indications were aseptic loosening in 83% and two-stage exchange after periprosthetic joint infection in 17% of cases. Mean follow-up period was 72 months. Femoral megaprostheses were used in 13% of cases. Most defects were classified as Paprosky 3b (29%). Function was assessed using the Harris Hip score.

Results

Aseptic cup survivorship was 80% at 104 months (95% Confidence Interval 67.4–92.4). Overall implant survival was 73%. Major bone loss defects (Paprosky types 2c to 3b) were associated with a significantly higher rate of failure than minor defects (P = 0.002). There were eight cases of aseptic loosening (19.5%) and two of infection (4.9%). Previous surgeries, indication for acetabular revision, patient-related risk factors and use of megaprostheses did not significantly influence implant survival. The Harris Hip Score improved from a median of 40 (Interquartile range 31–45) to 82 (interquartile range 65–88) postoperative (P < 0.0001).

Conclusions

In summary, the use of porous tantalum metal implants in acetabular revision surgery achieves good to excellent short- term and mid-term functional results and an acceptable complication rate relative to the extent of defect and previous surgery. However, one should be aware of potential limitations of the implants in addressing large defects and discontinuity.

Total femoral replacement for salvage of periprosthetic fractures

Patients with complex periprosthetic fracture patterns of the femur may ultimately require amputation. Some authors have described the use of mega-endoprostheses as a salvage procedure. This study reports functional outcome, complications, and implant and patient survival after total femoral replacement (TFR) for salvage of periprosthetic fracture of the femur. A prospective database of 20 consecutive patients who underwent TFR for salvage of a periprosthetic fracture was compiled. Patient demographics, mobility information, and preoperative and postoperative Short Form 12-item Survey (SF-12) and 1-year Toronto Extremity Salvage Score (TESS) data were recorded. Postoperative complications were obtained from the hospital database and patient medical notes. One patient was lost to follow-up and was excluded from analysis. The study included 8 men and 11 women, with a mean age of 68.4 years. No significant difference was noted in the prefracture physical (4.4; P=.13) or mental (0.3; P=.78) component scores of the SF-12 compared with 1-year scores. The TESS at 1 year was 69%. However, patients were more likely to require a walking aid postoperatively (P<.0001). One-fourth of the patients had a postoperative medical complication. In addition, 1 patient had a dislocation and 2 patients had a periprosthetic infection. The implant survival rate was 86% at 10 years; however, the 10-year mortality rate was 58%. Although TFR for salvage of a periprosthetic fracture of the femur offers good functional outcome and implant survival, it is at the expense of postoperative complications, and TFR is associated with a high long-term mortality rate.

Custom intramedullary intercalating device for treatment of supracondylar fracture between constrained total knee arthroplasty and well-fixed total hip arthroplasty

Management of periprosthetic fractures between ipsilateral total knee arthroplasty (TKA) and total hip arthroplasty (THA) is difficult, and is further complicated in the setting of poor femoral bone stock. We present a case of supracondylar fracture between THA and long-stemmed TKA femoral components in a patient with rheumatoid arthritis, deficient metaphyseal bone stock, and recurrent fractures. A long custom intramedullary intercalating component was devised to link the well-fixed existing THA stem to a revision distal femoral component. The resulting construct was stable and allowed for full weight-bearing ambulation, representing a useful treatment option in the management of periprosthetic fractures between revision TKA and well-fixed THA.

Salvage of an infected periprosthetic failed fracture fixation in a nonagenarian

Infected nonunions resulting in segmental bone loss are a devastating complication for patients and a difficult problem for surgeons. Adequate soft tissue coverage, return of mobility, fracture stability, and long-term freedom from infection are all important goals of treatment. Although there are numerous published studies that provide some treatment guidelines, there are patients who require unique and individualized solutions. In this report, we present a case in which an antibiotic-impregnated cement spacer was used as a component of the definitive treatment in a geriatric patient with segmental bone loss of the femur secondary to severe infection as a salvage technique to avoid amputation.