Infected total femoral replacements: evaluation of limb loss risk factors

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.

Single-Stage Revision of Infected Total Femoral Replacement

We present 2 cases of infected total femur prosthetic devices treated with a single-stage revision with extensive irrigation and debridement, followed by reimplantation with a prosthesis coated in antibiotic-impregnated cement. Single-stage total femoral replacement with antibiotic-eluting cement around the device was used for 2 cases of limb salvage arthroplasty to reduce complications, maintain patient function, and minimize hospital-associated cost. [Orthopedics. 2022;45(5):e280-e283.].

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

»

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.

»

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.

»

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.

»

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.

»

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.

Revision Arthroplasty with Total Femur Replacement for the Management of Complex Post-traumatic Bone Defect in a Patient with Dwarfism

Dwarfism leads to an early onset of osteoarthritis of the joints of the lower limb. Due to bone deformities, arthroplasty is challenging. The incidence of implant-associated complications is higher compared to the normal population and often ends up with multiple revision arthroplasties. We report the first case in the literature of a 48-year-old patient with dwarfism who required implantation of a custom-made total femoral replacement due to aseptic stem loosening and a concomitant valgus gonarthrosis.

[Total endoprosthetic replacement of femur, humerus and tibia]

Improvements in diagnostics and effectiveness of chemotherapy have resulted in most patients with primary malignant bone tumours being candidates for limb salvage surgery. Herewith, the use of modern modular tumour endoprostheses allows for the replacement of all big joints and even entire long bones such as the femur, humerus and tibia. In this article, we focus on individual prerequisites for and challenges with performing a total endoprosthetic reconstruction of the above-mentioned anatomic structures. Additionally, data from the literature with regards to functional outcome, problems and complications are presented.

[Advances in total femur replacement]

Objective

To summarize the advances of total femur replacement in recent years.

Methods

The literature related to total femur replacement was reviewed, and the indications, techniques, prosthesis design, complications, rehabilitation, and function were summarized.

Results

The indication of total femur replacement is a wide involvement of the femur, skip lesions and a huge bone defect in revision. Watson-Jone is the main incision in the proximal, and then the full length of the thigh to the patella. Vascular and nerve bundle, abduction muscles are well protected, and combined or costumed prosthesis are replaced. The prosthesis design progresses, showing a diversified prostheses. Complication is frequent and varied. Rehabilitation in early stage is physical therapy, weight training is evolutionary. The main function evaluation system is Musculoskeletal Tumor Society (MSTS) score.

Conclusion

Total femur replacement is effective in limb salvage. Large sample size and long-term follow-up study should be carried out to unify indications and functional exercise standards and reduce postoperative complications.

Ipsilateral Arteriovenous Loop and Latissimus Dorsi Free Flap for Knee Reconstruction in an Elderly Patient: A Case Report

Herein, we report an unusual indication of an arteriovenous (AV) loop with a latissimus dorsi free flap after wound-edge necrosis in an 81 year old patient. The patient underwent multiple revision procedures after total knee arthroplasty and total hip arthroplasty. After a dramatic reduction of femoral bone, a total femoral replacement was performed. The lateral knee incision wound was broke down and the hardware became exposed. Local flaps were not available and a free flap with an ipsilateral AV loop from the great saphenous vein was used to cover the large defect. The functional status of the hip and knee joints was good after 6 months, and enough the patient was able to ambulate without any assistance. The patient did not show any signs of infection.

Current concepts in total femoral replacement

Total femoral replacement (TFR) is a salvage arthroplasty procedure used as an alternative to lower limb amputation. Since its initial description in the mid-20^th century, this procedure has been used in a variety of oncologic and non-oncologic indications. The most compelling advantage of TFR is the achievement of immediate fixation which permits early mobilization. It is anticipated that TFR will be increasingly performed as the rate of revision arthroplasty rises worldwide. The existing literature is mainly composed of a rather heterogeneous mix of retrospective case series and a wide assortment of case reports. Numerous TFR prostheses are currently available and the surgeon must understand the unique implications of each implant design. Long-term functional outcomes are dependent on adherence to proper technique and an appropriate physical therapy program for postoperative rehabilitation. Revision TFR is mainly performed for periprosthetic infection and the severe femoral bone loss associated with aseptic revisions. Depending on the likelihood of attaining infection clearance, it may sometimes be advisable to proceed directly to hip disarticulation without attempting salvage of the TFR. Other reported complications of TFR include hip joint instability, limb length discrepancy, device failure, component loosening, patellar maltracking and delayed wound healing. Further research is needed to better characterize the long-term functional outcomes and complications associated with this complex procedure.