The push-through total femoral prosthesis offers a functional alternative to total femoral replacement: a case series

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.

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.

Total femur replacement with 18 years of follow-up: A case report

BACKGROUND

Osteosarcoma is one of the most common primary malignant bone tumors and is more common in adolescents. The femur is the most common site of osteosarcoma, and many patients require total femur replacement. We reviewed the relevant literature and case findings, summarized and analyzed this case in combination with relevant literature, and in doing so improved the understanding of the technology.

CASE SUMMARY

The case we report was a 15-year-old patient who was admitted to the hospital 15 days after the discovery of a right thigh mass. The diagnosis was osteosarcoma of the right femoral shaft. After completion of neoadjuvant chemotherapy and preoperative preparation, total right femoral resection + artificial total femoral replacement was performed. Then, chemotherapy was continued after surgery. The patient recovered well after treatment, and the function of the affected limb was good. No recurrence, metastasis, prosthesis loosening, dislocation, fracture or other complications were found during 18 years of follow-up. At present, the patient can still work and lives normally. The results of the medium- and long-term follow-up were satisfactory.

CONCLUSION

Artificial total femur replacement is a feasible limb salvage operation for patients with femoral malignant tumors, and the results of medium- and long-term follow-up are satisfactory.

Outcomes and complications following non-oncologic total femoral replacement

BACKGROUND

Non-oncologic total femoral replacement (TFR) is utilised as a limb-salvage option in the setting of massive bone loss during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, complication rates, including infection and reoperation, remain a concern.

METHODS

In this study, 16 consecutive TFRs from a single institution with an average clinical follow-up of 4 years were retrospectively reviewed. Indications for TFR, previous surgeries, implants used, complications, reoperations, and ambulatory status at final follow-up were recorded.

RESULTS

The reoperation rate was 50%, and those patients averaged 2 additional surgeries after TFR. The most common reason for reoperation was infection with a 33% incidence of a new periprosthetic infection and an overall infection rate of 44% (7/16). 6/7 were managed with irrigation and debridement and implant retention. Dual-mobility and constrained acetabular liners were used consistently, and no patient experienced a subsequent dislocation. At final follow-up, 81% were ambulatory but only 2 patients (13%) could walk without an assistive device. No patient required amputation.

CONCLUSIONS

While TFR achieved limb salvage in all patients with fair clinical outcomes, patients were at high risk for new or persistent infection and reoperation. Dual-mobility and constrained acetabular liners were effective in preventing dislocation is this cohort.

Advances in tumour endoprostheses: a systematic review

Tumour endoprostheses have facilitated limb-salvage procedures in primary bone and soft tissue sarcomas, and are increasingly being used in symptomatic metastases of the long bones.

The objective of the present review was to analyse articles published over the last three years on tumour endoprostheses and to summarize current knowledge on this topic. The NCBI PubMed webpage was used to identify original articles published between January 2015 and April 2018 in journals with an impact factor in the top 25.9% of the respective category (orthopaedics, multidisciplinary sciences).

The following search-terms were used: tumour endoprosthesis, advances tumour endoprosthesis, tumour megaprosthesis, prosthetic reconstruction AND tumour. We identified 347 original articles, of which 53 complied with the abovementioned criteria.

Articles were categorized into (1) tumour endoprostheses in the shoulder girdle, (2) tumour endoprostheses in the proximal femur, (3) tumour endoprostheses of the knee region, (4) tumour endoprostheses in the pelvis, (5) (expandable) prostheses in children and (6) long-term results of tumour endoprostheses.

The topics of interest covered by the selected studies largely matched with the main research questions stated at a consensus meeting, with survival outcome of orthopaedic implants being the most commonly raised research question.

As many studies reported on the risk of deep infections, research in the future should also focus on potential preventive methods in endoprosthetic tumour reconstruction.

Cite this article: EFORT Open Rev 2019;4:445-459. DOI: 10.1302/2058-5241.4.180081